Available online at www.researchinformation.co.uk Research The Journal of Grey System Information Volume 27 No.1, 2015

Evaluation of Work Efficiency and Medical Quality for a Hospital on the PPP Model in China with Benchmarking and GRA

Xiaoning Li1, Xinbo Liao1,2∗, Xuerui Tan3, Kai Zheng4, Xiaoping Xu5, Xiaojun Chen3

1. School of Public Health, Sun Yat-sen University, 510080, P.R. China (The first author now is working at Clinical Services Department, The University of Hong Kong- Hospital, Shenzhen 518053, P.R. China.) 2. Department of Health of Province, Guangzhou 510060, P.R. China 3. The First Affiliated Hospital of University Medical College, Shantou, 515041, P.R. China 4. School of Public Health, Jilin Medical College, Jilin 132013, P.R. China 5 .The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, P.R. China

Abstract Work efficiency and medical quality are two main hospital performance indicators in "Indicators of medical quality management and control on the third level large general hospital (2011 edition)” issued by National Ministry of Health. Benchmarking and grey relational analysis (GRA) are put into use to construct accessing model to evaluate work efficiency and medical quality for a hospital on public private partnership (PPP) model (Chaonan Minsheng Hospital of Guangdong Province) between 2007 to 2011，a total of 10 indicators. Evaluating results of work efficiency and medical quality for a hospital on the PPP model could be obtained and discussed. The predicting trend of future development and suggestions for better development of a hospital on the PPP model may provide some useful information for the government of Chaonan , The First Affiliated Hospital of SUMC and investor. And then, it does good to the management and development of the hospitals on PPP model.

Keyword: Grey Relational Analysis; Benchmarking; Evaluation; Work Efficiency; Medical Quality; Hospital on PPP Model

1. Introduction “Public private partnerships (PPP) refers to a long-term, contractually regulated co-operation between the public and private sector for the efficient fulfillment of public tasks in combining the necessary resources (e.g. know-how, operational funds, capital, personnel) of the partners and distributing existing Hospital project risks appropriately according to the risk management competence of the Grey

Evaluation ∗ Corresponding author: Xinbo Liao, Department of Health of Guangdong Province, Guangzhou 70 510060, P.R. China; Email:[email protected]

Xiaoning Li et al/ The Journal of Grey System 2015 (27) project partners”[1]. Sharing risks and responsibility, improving efficiency, reducing cost, introducing competition, etc., are advantages of PPP [1-3]. The purpose of PPP is to transfer tasks and responsibility for the provision of infrastructure to the private sector, for gaining high efficiency, cost reliability and financial security [1]. Hyun Sook Lee [4] believed that applying PPP was the guarantee of position of exceptional comparative advantage of international expertise in the field of healthcare. A PPP can combine the strengths of private actors and the role of public actors to create an enabling environment for delivering high quality health infrastructure and services [5]. The appealing of program and goals of PPP to the motivations of the partners are critical factors for successful partnerships [6]. Good communication and relationships, support from authorities, perseverance and commitment were identified facilitators for PPP. Lack of leadership, skills and attitude (non-compliance, negative attitudes) were identified barriers towards PPP [7]. Carlos Oliveira Cruz and Rui Cunha Marques found that the main advantage of a PPP project for health care is to introduce the private sector’s commercial and profit-oriented approach to the delivery of an expensive public service [8]. Policies of “Notice for guidance of trial reform on public hospital” and “Guidance of further encouraging and leading private capital to set up medical institutions” issued by Chinese government are advocate private capital to set up medical institutions, in order to increase health resources and improve medical service efficiency and quality. Under these reform policies for private capital, Chaonan Minsheng Hospital of Guangdong Province was established by the government of Chaonan district, Shantou city, Guangdong Province, The First Affiliated Hospital of Shantou University Medical College (SUMC) and investor, becoming an earlier hospital on public private partnership (PPP) model [9]. Cheng Zhe and Wang Shou Qing constructed a development model of private capital delivering medical institutions, which provided practical reference for the participants [10]. Work efficiency and medical quality are the two main hospital performance indicators in "indicators of medical quality management and control on the third level large general hospital (2011 edition)” issued by the National Ministry of Health in China. Work efficiency and medical quality are also proposed in “guideline of evaluation on hospital management (2008 edition)” issued by the National Ministry of Health in China. Work efficiency and medical quality are important indicators to evaluate management and operations. Indicators of work efficiency include average hospitalization days, working days per bed, bed utilization rate and hospital beds turnover and indicators of medical quality include coincidence rate of pathologic examination and clinical diagnosis, rescuing critically ill patients on emergency, successful rate of rescuing critically ill patients on emergency, rescuing critically ill inpatients, successful rate of rescuing critically ill inpatients, class-I healing rate of aseptic incision and so on, which are proposed in "indicators of medical quality management and control on the third level large general hospital (2011 edition)” issued by the National Ministry of Health in China.

2. Theory of GRA GRA was proposed by Deng Julong in the 1980s [11-13], which plays an important part in many areas. The foundational thought of GRA is judging the Hospital closeness for the relationship of sequences from the similar level of geometry of the Grey sequence curve-the closer the curve is the bigger the degree of interaction between [13,14] Evaluation corresponding sequences, conversely, the further the smaller . GRA has been 71

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widely applied in many fields. In recent years, GRA is often applied in healthcare industry. In the aspect of hospital evaluation and analysis, GRA is applied to evaluate the financial burden of patients for a hospital on the PPP model [9], resource configuration and service ability for a hospital on the PPP model [16], medical quality [17], drug price regulation of public hospitals[18]，develop an evaluation method for selecting the optimal medical tourism alliance [19] ， concentration of medical resources [20], demand forecast for emergency resources [21] and so on. In the aspect of relevant influential factors analysis for the hospital, GRA is put into use in influential factors the hospital medical expenditure [22], influential factors of inpatient medical expense for angina patients [23], main factors influencing business income in the hospital [24], influential factors for Chinese medicine [25], sexual satisfaction and hemoglobin in essential hypertensive patients [26] , main influential factors of setting up opening hospital beds for departments [27], relevant factors of general income in the hospital [28], influence factors of average hospitalization days [29] and so on. GRA is also applied in public health service [30], such as influential factors of inpatients' cost in new rural cooperative medical scheme [31] and influential factors of new rural cooperative medical scheme [32], influential factors of community health services [33,34], occupational health supervision and quality evaluation [35,36] improving service quality of nursing homes [37] and so on. GRA is suitable for evaluating the work efficiency and medical quality for a hospital on the PPP model since it has no special requirements for sample count and data distribution. Deng’s correlation degree is a method of GRA, which was first proposed by professor of Julong Deng and developed by Sifeng Liu. The bigger the value for correlation degree, the correlation between reference sequence and comparison sequence is closer. [14, 15] Deng’s correlation degree is selected to access work efficiency and medical quality of a hospital on the PPP model in this study. A hospital on the PPP model is a completely new hospital model comparing with traditional public hospitals and private hospitals. We wonder whether work efficiency and medical quality of a hospital on the PPP model are better or worse than traditional public hospitals and private hospitals. The purpose of this study is to evaluate work efficiency and medical quality of a hospital on the PPP model. The reasons why we choose GRA for analysis are that Chaonan Minsheng Hospital of Guangdong Province opened in 2006, and does not have much in terms of historical data for use with statistical and other mathematical methods[9,16]. However, GRA has the right function of solving the problems of uncertainty information involving multiple attributes, small sample size and non-normal distribution[14,38]. The evaluating results may provide some useful information for the government of Chaonan district, The First Affiliated Hospital of SUMC and investor. And then, it does good to the management and development of the hospitals on PPP model.

3. Construct accessing model for work efficiency and medical quality of a hospital on the PPP model basing on benchmarking and GRA American Productivity and Quality Center (APQC) defined benchmarking as Hospital "Benchmarking is a systematic and continuous evaluation process, in order to get Grey help to improved operational performance of consultation through constant [39] Evaluation comparison of organization process and global business leaders. Benchmarking 72 originated from Western countries in the 1980s, which was honored as a kind of

Xiaoning Li et al/ The Journal of Grey System 2015 (27) new management ideas and methods and was widely regarded as a better or best practices process for improve performance [40,41]. Benchmarking can be divided into process benchmarking and consequence benchmarking. Key steps of benchmarking are as follows [40]. Firstly, determine the benchmarking program and have a thorough knowledge of the program. Secondly, select benchmarking partners and have full knowledge of their practices. Thirdly, compare the selected process with partners to find the gap and realize improvement with changes. Fourthly, introduce best practices and supervise performance of best practices. We adopt consequence benchmarking and GRA to construct accessing model for work efficiency and medical quality for a hospital on the PPP model. The steps are as follows basing on a series of benchmarking activities. (1) Determine benchmarking objects. Conform indicators of work efficiency and medical quality for a hospital on the PPP model through literature retrieval and the policy of "indicators of medical quality management and control on the third level large general hospital (2011 edition)” issued by National Ministry of Health in China. At last, we select 10 indicators of work efficiency (including average hospitalization days, working days per bed, bed utilization rate, hospital beds turnover) and medical quality (including coincidence rate of pathologic examination and clinical diagnosis, rescuing critically ill patients on emergency, successful rate of rescuing critically ill patients on emergency, rescuing critically ill inpatients, successful rate of rescuing critically ill inpatients, class-I healing rate of aseptic incision) as benchmarking objects. (2) Select benchmarking partners，meaning determine comparison objects for a hospital on the PPP model (Chaonan Minsheng Hospital of Guangdong Province).

Table 1 Data of work efficiency and medical quality for hospital on PPP model indicators 2007 2008 2009 2010 2011 work efficiency work efficiency average hospitalization days 6.52 6.66 7.03 6.95 6.85

working days per bed 282.19 309.00 380.97 321.87 288.57

bed utilization rate(%) 77.31 84.66 104.38 88.18 79.06

hospital beds turnover(%) 43.25 46.24 53.79 45.94 42.73 medical quality medical quality coincidence rate of pathologic 96.76 97.43 97.10 97.28 97.08 examination and clinical diagnosis(%) rescuing critical ill patient on emergency 1682 1573 1716 2575 2506 successful rate of rescuing critical ill 97.92 97.65 97.44 97.86 98.56 patient on emergency (%) rescuing critical ill inpatient 439 413 492 730 667 successful rate of rescuing critical ill 97.06 87.75 87.54 87.59 88.53 inpatient(%) class-I healing rate of aseptic incision(%) 99.32 99.40 99.81 99.21 99.48

We choose a public hospital which was located at the same city with a hospital on the PPP model and a private hospital from another city of Guangdong Province. The above three hospitals all come from an undeveloped region of Guangdong Province in order to make sure the comparability of benchmarking partners. Data Hospital for the indicators for work efficiency and medical quality come from the department of statistics for the hospitals on the PPP model (Chaonan Minsheng Grey Hospital of Guangdong Province), public hospital and private hospital and Evaluation 73

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information center for health statistics from the Department of Health of Guangdong Province. In order to carry out horizontal comparison of work efficiency and medical quality for a hospital on the PPP model (Chaonan Minsheng Hospital of Guangdong Province), public hospital and private hospital, 5 years worth of data of work efficiency and medical quality, a total of 10 indicators between 2007 to 2011 from those three model hospitals are applied in this study (see Table 1, Table 2, Table 3). Hospital beds for a hospital on the PPP model (Chaonan Minsheng Hospital of Guangdong Province), the public hospitals and the private hospitals are respectively 377, 400 and 349 in 2007. The scale of three model hospitals are all in secondary at the beginning.

Table 2 Data of work efficiency and medical quality for public hospital indicators 2007 2008 2009 2010 2011 work efficiency work efficiency average hospitalization days 6.32 6.46 6.43 7.02 6.79 working days per bed 186.57 222.68 253.29 316.92 289.83 bed utilization rate(%) 51.12 61.01 69.39 86.83 79.41 hospital beds turnover(%) 29.52 34.18 39.11 44.68 42.57

medical quality medical quality coincidence rate of pathologic 97.97 98.00 97.05 97.08 96.98 examination and clinical diagnosis(%) rescuing critical ill patient on 356 110 407 523 558 emergency successful rate of rescuing critical ill 88.48 90.00 96.56 98.77 96.95 patient on emergency (%) rescuing critical ill inpatient 73 59 70 77 154 successful rate of rescuing critical ill 97.17 97.27 97.73 97.85 98.02 inpatient(%) class-I healing rate of aseptic 97.50 98.80 99.24 99.76 99.52 incision(%)

Table 3 Data of work efficiency and medical quality for private hospital

indicators 2007 2008 2009 2010 2011 work efficiency average hospitalization days 9.36 10.84 10.52 8.60 8.96 working days per bed 266.69 266.40 243.64 252.35 277.65 bed utilization rate(%) 73.07 72.99 66.75 69.14 76.07 hospital beds turnover(%) 28.51 18.44 16.51 18.15 18.44 medical quality medical quality coincidence rate of pathologic examination and clinical 95.09 100.00 100.00 100.00 100.00 diagnosis(%) rescuing critical ill patient on 662 544 1113 1465 1461 emergency successful rate of rescuing critical 97.73 96.51 97.39 99.45 98.70 ill patient on emergency (%) rescuing critical ill inpatient 411 375 230 350 326 successful rate of rescuing 97.50 97.12 97.05 98.54 97.24 critical ill inpatient(%) class-I healing rate of aseptic 99.52 95.68 99.82 99.68 99.73 Hospital incision(%) Grey Evaluation (3) Find the gap of work efficiency and medical quality between a hospital on the 74 PPP model and the public and private hospital, in order to make improvement

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through GRA evaluation. The principle of determining reference system of indicator are maximum value for benefit indicator, minimum value for cost indicator, closing to a constant value for moderate type indicator and a certain range of values within an interval for interval type indicator[42]. We select the idea value for every indicator of work efficiency and medical quality basing on this principle. Ideal value of each year for average hospitalization days is selected from this indicator of a hospital on the PPP model, the public hospital and the private hospital from 2007 to 2011. From the view of work efficiency, the evaluation of average hospitalization days is the smaller the better. So we choose the smallest value from average hospitalization days of hospital on PPP model, public hospital and private hospital as the ideal value in each year. Then, we get the ideal sequence

Xxxxx(0) =（0000 (1), (2), (3)= (4)） =（6.32, 6.46, 6.43, 6.95, 6.85） Comparison sequences are XX(1), (2), X (3) (see Table 4).

Table 4 Value of average hospitalization days for three model hospitals and optimal value sequence (day) 2007 2008 2009 2010 2011

Optimal value 6.32 6.46 6.43 6.95 6.85

hospital on PPP model 6.52 6.66 7.03 6.95 6.85 Public hospital 6.32 6.46 6.43 7.02 6.79 Private hospital 9.36 10.84 10.52 8.60 8.96

Table 5 Deng's correlation degree of indicators of work efficiency and medical quality for three model hospital and evaluating result

correlation degree evaluating result indicators PPP public private PPP f public PPP f private average hospitalization days No Yes 0.8100 0.9592 0.5217 working days per bed Yes Yes 0.9968 0.6785 0.7351 bed utilization rate Yes Yes 0.9968 0.6787 0.7351 frequency of hospital beds turnover Yes Yes 1.0000 0.6879 0.5411 coincidence rate of pathologic examination 0.5947 0.4891 0.4667 Yes Yes and clinical diagnosis rescuing critical ill patient on emergency Yes Yes 1.0000 0.7567 0.5578 successful rate of rescuing critical ill patient 0.9457 0.5515 0.9471 Yes No rescuing critical ill inpatient Yes Yes 1.0000 0.6552 0.6092 No successful rate of rescuing inpatient No 0.4842 0.9469 0.9514 Hospital class-I healing rate of aseptic incision Yes Yes 0.9376 0.6523 0.8109 Grey Evaluation We can use the same method to calculate the correlation degree for the other nine 75

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indicators of work efficiency and medical quality for a hospital on the PPP model, the public hospital and private hospital from 2007 to 2011. The value of working days per bed, bed utilization rate and hospital beds turnover is the bigger the better, suggesting that the hospital work efficiency is higher. From the perspective of medical quality, the value for coincidence rate of pathologic examination and clinical diagnosis, rescuing critically ill patients on emergency, successful rate of rescuing critically ill patients on emergency, rescuing critically ill inpatients, successful rate of rescuing critically ill inpatients, class-I healing rate of aseptic incision is the bigger the better. So we choose the biggest value of these indicators in a hospital on the PPP model, the public hospital and the private hospital has the ideal value in each year from 2007 to 2011. (4) Introduce best practices and supervise performance of best practices. The evaluating result can be taken from ordering correlation degree (see Table 5) from the above step. The criteria of which model hospital (the hospital on the PPP model, the public hospital and the private hospital) is the best is that more than 50% of indicators on one model hospital are assessed as better than the other model hospital through GRA evaluating results. In this method, we can find which model hospital is the best developing from the evaluation with GRA. From table 6, we find that more than 75% indicators of work efficiency (total 4 indicators) and more than 67% indicators of medical quality (total 6 indicators) are assessed as“ the hospital on the PPP model f the public hospital” or “the hospital on the PPP model f the private hospital” from Deng’s correlation degree.

Table 6 The evaluating result from four grey relational analysis models (The number of indicators)

work efficiency (4 indicators) medical quality (6 indicators) model PPP f public PPP f private PPP f public PPP f private Deng’s correlation 3 4 5 4 degree

4. Discussion and conclusion We can conclude that work efficiency (total 4 indicators) and medical quality (total 6 indicators) of the hospital on the PPP model are equal and even better than the public hospital and the private hospital in the past five years from 2007 to 2011 based on the evaluation of GRA. But we could not judge that the hospital on the PPP model is superior to the public hospital and the private hospital only from the result of GRA evaluation, since the result of evaluation has a high correlation with references. Factors of policy and economics should be included to evaluate the development of the hospital on the PPP model for the past five years. The reasons why work efficiency (total 4 indicators) and medical quality(total 6 indicators) for the hospital on the PPP model develops so fast is that it is supported by The First Affiliated Hospital of SUMC, investor, local government and patient. Evaluation of work efficiency (total 4 indicators) and medical quality(total 6 indicators) for the hospital on the PPP model with GRA makes the results quantified and objective and provides reference for decision-making and Hospital management for participants. Grey Through evaluation, we can judge that whether a hospital on the PPP model reached the purpose of improving medical service efficiency and quality proposed Evaluation by policies of “notice for guidance of trial reform on public hospital” and 76

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“guidance of further encouraging and leading private capital to set up medical institutions” issued by the Chinese government. Contributions of this study are suggested in the following aspects. On the one hand, the statistical analysis method needs big sample and large data, but GRA only needs 3 or more data which makes up for the inadequacy of the statistical method[15]. On the other hand, GRA and benchmarking methods are combined to evaluate a hospital on the PPP model, extending the application of GRA in hospital management. This evaluating method provides a train of thought and practice for quantitative evaluation in the new hospital on the PPP model.

5. Trend of future development and suggestions for a hospital on the PPP model The trend of future development for a hospital on the PPP model is predicted as follows; undeveloped regions and remote areas have the most lack of medical resources in China. However, financial resources from local government is very limited and is difficult to invest a lot of human resource, material resource and financial resource to meet the public demand for medical resources in a short time. PPP is widely used in Western countries. Additionally, the public hospitals have a long history and has accumulated rich medical experience and abundant human capital in China. In the aspect of Chinese government, with the policies of “Notice for guidance of trial reform on public hospital” and “Guidance of further encouraging and leading private capital to set up medical institutions” issued by government, suggest that Chinese government advocates private capital to set up medical institutions, in order to increase health resources and improve medical service efficiency and quality. So, the timely introduction of private capital for development of medical service is very important and the hospital on the PPP model will become more and more popular in China. Suggestions for better developing hospital on PPP model are as follows. First, laws and regulations of developing hospital on the PPP model should be perfected by Chinese government. The responsibility of each participant of a hospital on the PPP model, such as government, investors and managers should be very clear, in order to ensure high work efficiency and medical quality. Second, give full play to the dominant and supervision function of Chinese government for hospitals on the PPP model. A series of preferential and supporting policies should be laid down by the Chinese government to attract private capital or foreign capital to invest in health services, especially in those undeveloped areas and remote areas where the most lack of medical resources are. The government should strengthen its role of supervision and management, in order to ensure smooth running and public welfare of hospitals on the PPP model and to prevent the loss of state-owned assets. Third, allow full play to public hospitals in advantage of human resources for developing hospitals on the PPP model, in order to improve work efficiency and medical quality. Public hospitals have a long history and have accumulated rich medical experience and abundant human capital in China. Human resources of public hospitals and capital resources of private hospitals should be integrated through rational guidance and supporting policy of Chinese government. Hospital Acknowledgements Grey The relevant studies done in this paper are supported by National Natural Science Evaluation Foundation of China （No. 81172776）and High-level talents project of Guangdong 77

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