HRM report on Aga khan hospital Karachi that includes performance indicators.

1. HPM REPORT (AGHA KHAN
HOSPITAL CASE)
ANAM SHAHID

2. TABLE OF CONTENTS
1.INTRODUCTION
2.PM DEFINITION
3.PM IN HEALTHCARE
4.PM IN HEALTHCARE SETUP OF PAKISTAN
5.HOSPITAL PROFILE:
 MISSIONVISION
 HOSPITAL PHILOSOPHYABOUT pm
 PERFORMANCEMODEL
6.PERFORMANCE INDICATORS
7.CONCLUSION
8.RECOMMENDATIONS

3. DEFINITION
Performancemanagement is a forward-looking process used to set goals and
regularly check progress toward achieving thosegoals. In practice, an
organization sets goals, looks at the actual data for its performancemeasures,
and acts on results to improve the performancetoward its goals.
Why Doesan Organization Need to Measure Performance?
 Distinguish whatappearsto be happening fromwhat is really happening
 Establish a baseline; i.e., measurebefore improvements are made
 Make decisions based on solid evidence
 Demonstratethat changes lead to improvements
 Allow performancecomparisons acrosssites
 Monitor process changes to ensure improvements aresustained over
time
 Recognize improved performance
Process Map of PerformanceManagement Pathway

4. Organizational (internal) prerequisites
 Adequate pay levels
 Staff have the equipment, tools and skills to do their job
 Achieving the right balance of incentives for staff to performwell
 Local autonomy and decision making
 Familiarity with planning methods
 Effective communications
 Leadership and effective management systems
 A culture of accountability and openness
External prerequisites
 Political pressure and health care reforms
 Financialpressures
 Decentralization
 Pressure from service users and quality assurance

5. Health care system in Pakistan
 Public sector hospitals
 Private sector hospitals
 Faujifoundation hospitals
 Charity hospitals
 Health care insurance
Performance managementmethods
 Regulatory inspection
 Surveys of consumers’ experiences
 Third-party assessments
 Statistical indicators
 Internalassessments
 Accreditation & Certification Agencies requirements
VISION
Aga khan university hospitalwill be an autonomous, international institution of
distinction, primarily serving the developing world and Muslim societies in
innovative and enduring ways.
MISSION
AKU is committed to the development of human capacities through the
discoveries and dissemination of knowledge and application through service.
HOSPITAL HISTORY:
AKU hospitalKarachi started operation in 1985 as an integrated healthcare
delivery, component of AKU. Itis a philanthropic, privateteaching institution
committed to providing the best possibleoptions for diagnosis of diseaseand
team management of patient care.

6. Philosophy
AKUH operates on the core principle of
• Quality
• Relevance
• Impact
• Access

10. PERFORMANCE INDICATORS
DEFINITION:
How quicklythe warehouse of Agha khan is refilled.
FINDINGS:
The critical items warehouse fill rate is high as compare to non critical
items.

11. DEFINITION:
Regulatory reporting’s to the regulatory/governmentauthorities on time.
FINDINGS:
They excel in the timely reporting to the regulatory authority.

12. DEFINITION:
Rate of sensitivecomplains
FINDINGS:
In the ending quarter of 2009 they exceed the limit range but in 2010 they
controlled it.

13. DEFINITION:
The ratio of testingthe compatibilityofdonor,recipient & the
transfusion.
FINDINGS:
They havebetter results but still need to work on this indicator.

14. DEFINITION:
What is the patient satisfaction ratio?
FINDINGS:
They set the limit on 90% but still they hasn’t reached that limit.They
need to work on this indicator.

15. DEFINITION:
The staff satisfaction ratio.
FINDINGS:
The patient satisfaction ratio was higher in 2009 as compare to 2010.

16. DEFINITION:
Indicatorthat shows how many users belongsto socio-
economic group.
FINDINGS:
They have a major no. of patientsfrom socio-economic
group.

17. DEFINITION:
Full time employees required to employ on particularno.of beds.
FINDINGS:
They got 4-5 employees per bed.

18. DEFINITION:
Quick & timelyresponse to fire emergency calls.
FINDINGS:
They have100% response to the fire emergency calls.

19. DEFINITION:
Timelyresponse to securityemergency calls.
FINDINGS:
In the first quarter theyresponded 98% while in the rest of the quarters
they responded 100%

20. DEFINITION:
Accidental puncture ofthe skin with an unsterilizedsyringe injuries.
FINDINGS:
The rate of injuries were rangingfrom 39-42.

21. DEFINITION:
Staff awareness related to FMS issues.
FINDINGS:
They set the target on 80% but still lesser than what they target.

22. DEFINITION:
Maintainingsafe environment in Psychiatry.
FINDINGS:
They excel theirworking in this dept.from the previous months.

23. DEFINITION:
Overall action of not complyingin medical record documentation.
FINDINGS:
In July 2010 the value cross the limit of 5% while from August to
December 2010 it was 5% i.e. the limit.

24. DEFINITION:
Reassessment of patients (follow ups)& the documentationofprogress
notes.
FINDINGS:
They put theirlimit at 10% but their working is better than the presumed
values.

25. DEFINITION:
The urgent laboratorytests report delay.
FINDINGS:
They set theirlimit at 2% but theirvalues are coming below 1%. Which
means they are doinggood in it.

26. DEFINITION:
Laboratoryqualitycontrol.
FINDINGS:
They set theirtarget at minimum 90% but values r higher than the limit.

27. DEFINITION:
How much time radiologytookto generate a report.
FINDINGS:
They havealmost achieved 100% in this indicator.

28. DEFINITION:
Prolongstay after day care surgery.
FINDINGS:
These values vary in four quarters of both years. Theyneed to work on
this indicator.

29. DEFINITION:
Rational usage of antibiotics.
FINDINGS:
They are more or less at the limit line that is 83%.

30. DEFINITION:
Medication errors per 100 patients.
FINDINGS:
They havea value of 2.5% error per 100 patient.

31. DEFINITION:
The compliance in the assessment of the patient before the
administrationofanesthesia.
FINDINGS:
They got an average of 92-98%

32. DEFINITION:
Incidences of blood transfusionreactions.
FINDINGS:

33. DEFINITION:
How much fast HMIS dept.is at the on time deliveryof medical record for
booked patients?
FINDINGS:
Only first quarter was belowthe limit line.In rest of the quarters the
range is 100%.

34. DEFINITION:
Medical record neglecting rate.
FINDINGS:
Its 15-15.5%

35. DEFINITION:
Intervention rate of emergency response coordinatoron submission of
research proposal.
FINDINGS:
They excel theirtarget i.e 100%

36. Internal Review Processes
•Departmental Quality Improvement Committees
•Joint Staff and its Sub-committees Reviews
•Patient Satisfaction
•Medical, Nursing and Others Health Professional Credentialing Programs
•Performance Appraisal Systems
Quality Audits
•ISO 9001:2008 Internal Audits
•JCIA Mock Surveys
•Closed and Open Medical Record Audits
•Clinical Audits
•Nursing Quality Improvement Audits
•Infection Control Audits
•Environment Safety Audits
•Risk Management
External review
 ISO 9001:2008
 ISO 22000:2005
 Joint Commission International Accreditation

37. CONCLUSION :
• Lower patient satisfaction and employee satisfaction
• Although it provides an outstanding work environment
• lack of staff awareness.
• Over rely on their brand image
• Inadequate referral system
• Expensive image
• Construction constraints
• Emerging new competitors for specialized services.
• They are not following the proper performance management model
RECOMMENDATIONS
• Quality department should develop a new performance management model.
• Information system is well develop and can help inbuilt a effective performance
management model.
• Should track down an integrated departmental system.
• Change management is required on management side of the institution.
• Ensure better use of resources and, therefore, increased efficiency and patient
satisfaction
• Quality standards should be known & practiced by all.
• Better compensation plan