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Monitoring health-care processes: a framework for

performance indicators
J.D. van der Bij and J.M.H. Vissers
Faculty of Technology Management, Eindhoven University of Technology,
The Netherlands
Until recently, it was uncommon to ask
professionals to provide non-professionals
with objective evidence regarding the quality
of their work. Nowadays, however, profes-
sionals and their health-care institutions
have to face assessments with respect to the
content of the work, as well as its organisa-
tion and control. This new setting resulted
from pressures effected by national govern-
ments and client(group)s. At the same time
health-care organisations are involved in
quality improvement programmes that will
encompass the rather isolated setting of
individual professionals, producing high-
quality work, but commonly operating with-
in the boundaries of their local unit Health-
care activities of individual professionals are
tuned to one another within the broader
framework of the patient process, and health-
care processes are redesigned within the
boundaries of a health-care organisation, or
beyond in a transmural perspective on
health-care processes delivered to patients by
different health-care organisations.
In all aforementioned situations informa-
tion is required on the current and in the
case of an intervention the new status of the
health care process. Often performance in-
dicators are suggested as key elements to
generate this information. It is not new to
pay attention to performance indicators in
health-care. In 1859 already Florence Night-
ingale tried to measure quality of care by
studying mortality rates and specific mor-
bidity rates (Nightingale, 1859). More re-
cently, Lohr mentioned health-care outcomes
including patient satisfaction, patient mor-
tality, unscheduled return to the operating
room and readmission within 72 hours of
discharge (Lohr, 1987). Donabedian refers to
three approaches on quality measurement
and monitoring: structure, process, and out-
come. All three approaches are complemen-
tary and should be used in a combined way
(Donabedian, 1966). Also the literature on
organisational effectiveness frequently refers
to performance indicators (Campbel, 1977;
Cameron, 1986; Lewin and Minton, 1986;
Quinn and Rohrbaugh, 1983). In our view the
discussion about performance indicators is
far from completed. On the contrary, it will
be stirred up by some of the aforementioned
practical issues as it will become a must to
have performance indicators to monitor and
evaluate health-care processes.
In this paper we will present a framework
of performance indicators and related mea-
surement tools to monitor and evaluate
health-care processes. It is based on a litera-
ture review and empirical research in two
general hospitals and one mental hospital.
The literature review was geared to the three
case studies, which served to develop and test
the framework.
First the concepts of monitoring and per-
formance indicators are treated. Next the
three cases are described. Then the frame-
work of performance indicators is presented.
Also some measurement tools are given that
were used to implement the indicators in the
case studies. Finally conclusions are drawn.
Monitoring and performance
In our view monitoring means portraying the
current status of a clearly defined object
system by measuring certain aspects. So, a
monitoring system is a representation of a
measurement system. The aim of monitoring
can be either control or evaluation. To be
able to control an object system, we need the
following (from Hofstede, 1981):
standards are available and unambiguous;
outputs are measurable;
effects of management interventions are
The current issue and full text archive of this journal is available at
[ 214]
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
# MCB University Press
[ISSN 0952-6862]
Performance indicators,
Health care,
Process management,
Until recently, it was uncommon
to ask professionals to give ob-
jective evidence to non-profes-
sionals regarding the quality of
their work. Nowadays, however,
professionals, their health-care
processes and their health-care
organisations have to face as-
sessments concerning organisa-
tion, control and content of the
work. Meanwhile, health-care or-
ganisations generate improve-
ment programmes to mutually
match activities of individual pro-
fessionals and to redesign health-
care processes within or between
health-care organisations. In all
these situations information is
required on the current and some-
times the improved stage of the
health-care process. Often perfor-
mance indicators are mentioned
to generate this information. In
this paper we present a framework
of performance indicators and re-
lated measuring instruments to
monitor and evaluate health-care
processes. It is based on a litera-
ture scan and on empirical re-
search in two general hospitals
and one mental hospital. The
literature scan was guided by the
three case studies and in the case
studies the framework was tested.
activities within the object system are
If these requirements are not fulfilled, it is
not possible to exert control. However, it is
possible to evaluate the object system in
terms of an assessment of the current status
of the system. On the basis of these results
the assessor might become curious and ask
for more and better information based on a
formalized and accepted measurement sys-
tem, as an assessment is often not made on
the basis of accepted standards for measuring
performance. Such a formalized and accepted
system for measuring performance is what
we are aiming at in this paper: a monitoring
system based on performance indicators.
In our view a performance indicator is a
means to measure the performance or an
aspect of the performance. It consists of an
operational measurement instrument and a
related scale. The use of performance indi-
cators to clarify and operationalise a re-
search question is a familiar procedure. For
instance, many performance indicators have
been suggested to clarify the construct of
organisational effectiveness. Unfortunately,
the large number of indicators with respect
to organisational effectiveness sooner mysti-
fies than clarifies the subject. In the quality
management literature people have tried to
clarify the concepts of organisational quality,
system quality, process quality and product
quality by mentioning performance indica-
tors for each concept (see one of the following
sections in this paper).
In health-care research, but also in health-
care practice, warnings are given against the
improper use of indicators to control or to
evaluate. Often in practice, the requirements
of Hofstede (1981) are not fulfilled, which
leads to misinformation regarding the mea-
surements. So, if indicators are really used
for management control, the circumstances
must be thoroughly investigated.
Case descriptions
The framework of performance indicators
and related measurement tools, which will be
treated in the following sections, was guided
by three studies. In this section case de-
scriptions are given. All case studies were
performed in a Dutch health-care setting.
The first case study concerns a general
hospital with 378 beds, an annual number of
200,000 out-patient visits, more than 20,000
admissions per year and a staff of 1,300
employees. During the past decade several
quality programmes have been set up. One of
the most important programmes is the so-
called ``patient routeing'' programme. In this
programme the routeing of the patient
through the hospital is described step by
step. For each step the aspects were estab-
lished that determine patients' satisfaction.
Those aspects were further elaborated to
factors that can be measured and for each
factor a standard for measurement was
established. To realise this patient perspec-
tive input there was close collaboration with
patient associations and consumer organisa-
tions. The factors and standards were dis-
cussed in a number of conferences. The
aspects of the patients' routeing are depicted
in Table I.
Based on these aspects, 230 factors were
traced in the patients' routeing. The current
status of the factors was investigated by
observations, interviews and surveys. This
investigation was very time-consuming, so
our assignment was to design a monitoring
system based on the patients' routeing that
would be more efficient.
The second case concerns an experiment
between a general hospital and a nursing
home. The hospital wished to concentrate
more on its primary treatment tasks and not
to accommodate patients who do not need
medical attention. Some of these patients,
however, could not go home because of their
physical condition or situation at home.
Presently these patients stay in the hospital
and occupy hospital beds for non-medical
reasons, whereas in the same period a patient
on the waiting list could have been helped. To
solve this problem the hospital was looking
for a partner that would be able to render the
care required by these patients for the
remaining part of the process. A nearby
nursing home was able to take over the
patients and act as a bridge for the period
until the patient could go home or to another
institution. During this period, which was
limited to a maximum of six weeks, the multi-
disciplinary way of working in the nursing
home could be used to improve the patient's
condition and prepare the patient for the
return home. This experiment with the so-
called after-care unit with 12 beds lasted for a
term of 18 months. The members of the
steering committee wanted to evaluate the
experiment. With the results of the evalua-
tion, the after-care unit was justified towards
the management of the two institutions, the
health insurance companies, and the profes-
sionals involved in the experiment. Possibly
the after-care unit can become a permanent
location. The evaluation could also be used to
adjust the care process at the two institu-
tions. Our assignment was to design a
monitoring system as a basis for evaluating
the experiment and adjusting the care pro-
cess if necessary.
[ 215]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
The third case concerns a mental hospital
that was recently merged with an out-patient
clinic for mental patients. As a result of this
merger the health-care activities have to be
tuned. It was decided to have a joint intake.
After the intake, the patient routeing is
established for each patient on the basis of
predefined standardised treatment plans. For
the new setting treatment plans have to be
designed as well as a common patient's
routeing with respect to each plan. This is
done in multidisciplinary teams. Our as-
signment was to design a monitoring system
for the adults' routeing including an assess-
ment of the quality of this routeing.
Framework of performance
indicators for health-care processes
In this section a framework of performance
indicators is developed. We will use the
assignments of the three case studies intro-
duced in section 3 as a starting-point. In the
assignments no distinction is made between
the health-care process considered and the
outcome of the process. However, this dis-
tinction is very difficult in health-care ser-
vices, as clients/patients participate in the
primary process. So, in this section we will
not make this distinction. It follows from the
assignments that indicators are required that
are closely related to the primary health-care
process. In fact, the aspects of the patients'
routeing (Table I) can be seen as examples of
indicators. In this section these indicators
are extended to a framework by reviewing
literature on different sources of inspiration:
production control and logistics, quality
control and control systems.
In production control theory a distinction
is made between control activities with a
global scope (patient-flow control) and con-
trol activities with a local scope (production
unit control). The aim of patient-flow control
is to realise the market performance that is
defined at the strategic management level;
the aim of unit control is to provide its
contribution to the service, conforming to the
specifications of patient-flow control in the
most efficient way. In the literature on
production control, performance indicators
are mentioned for both the global scope and
the local scope, for instance in Bertrand et al.
(1990) (Table II).
Often in health care the batch size and the
safety stock are not considered to be very
important. Nevertheless, one can interpret
the number of patients all visiting the clinic
of a specialist in the out-patient department
between 9.00 and 12.00 as a batch and the
number of patients that are overbooked for
the clinic can be seen as a safety stock for the
specialist to prevent his chance of running
In Nationale Raad voor de Volksgezond-
heid (1986) some useful indicators are men-
tioned concerning quality control in health
care (Table III). A distinction is made
between technical quality, relational quality,
and conditions to realise both kinds of
Note that the technical quality is not
defined in terms of outcomes, except for
effectiveness. Effectiveness needs elabora-
tion in a specific situation. This is our
general view with respect to outcome indi-
cators. These are very much related to and
determined by the specific situation. So, in a
general framework, outcome indicators can
only be mentioned in a global way. Moreover,
the process indicators for technical quality
give more information on the current status
in our view.
Indicators for a quality control system
were deduced from the Dutch PACE-stan-
dards. These standards are based on the ISO
9000 standards for quality assurance. The
PACE-standards (Pilotproject ACcrEditation)
have been being developed since 1990 by
eight Dutch hospitals and The Netherlands
Organisation for Applied Scientific Research.
The standards were developed for depart-
ments in a hospital. At first 21 standards
were developed; afterwards 14 standards
Table I
Aspects of the patients' routeing
Reachability by phone time until contact with a hospital employee has
been achieved
Access time time between making the appointment and the
visit in the hospital
Waiting time time between the planned and the actual visit
Information transfer transer of administrative and medical
information to the patient
Attitude human treatment of the patient
Layout of the health-care process
Attainability of the hospital by bus, train, car
Accessibility of the hospital for instance for handicapped persons
Facilities in the hospital
Cleaning of the hospital
Table II
Performance indicators from production theory
Patient-flow control Through-put time
Delivery reliability
Unit control Resource occupancy level
Resource utilisation rate
Batch size
Safety stock
Source: Bertrand et al., 1990.
[ 216]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
were added. For instance, at the moment
there are accepted standards for the admis-
sion office, diet care, ergotherapy, intensive
care, the nursing ward, laboratories, the
medical staff, out-patients' clinics and the
dispensary. The PACE-standards refer to the
policy and organisation;
means and materials;
control of the process;
knowledge and skills;
assurance of the quality system.
Indicators for health-care processes mainly
were deduced from the standards on control
of the process. These indicators are listed in
Table IV.
In 1995 the European Foundation for Quality
Management formulated guidelines for total
quality management in the public health
sector (European Foundation for Quality
Management, 1995). These guidelines are
based on a model of total quality manage-
ment defined by the European Foundation
for Quality Management. This model, which
is called the EFQM-model, elaborates the
concept of total quality management. The
model is illustrated in Figure 1. In the model
nine areas of attention are mentioned. Five of
these areas are input-oriented and four are
output-oriented. Examples of indicators are
given for the output-oriented areas in the
guidelines. In fact these indicators make the
concept of organisational quality opera-
tional. Some of these indicators can be
related to the primary process in health care.
This selection of indicators from the EFQM-
model are mentioned in Table V.
As a next step, we suggest a categorisation
for the performance indicators in Tables I-V
according to the following categories:
conditions for processes;
technical quality of processes;
relational quality in processes;
information, supporting processes;
production control, managing the logistics
of processes.
The first category (conditions) shows some
performance indicators whose placement in
this category is more or less arbitrary. Apart
from some overlap between performance
indicators, the other categories show consid-
erable correspondence between the refer-
ences used in this paper. This leads to a
preliminary framework for performance
Table III
Performance indicators from quality control in
health care
Technical quality Professionalism (of staff)
Precision (of treatment)
Capability (of staff)
Safety (lack of unsafe
Intake skills (of staff)
Relational quality
(including information)
Relationship based on trust
Information transfer
Accountability (of staff)
Conditions Continuity (of treatment)
Integrated care
Availability (of staff)
Source: Nationale Raad voor de Volksgezondheid
Table IV
Performance indicators from the PACE-standards
Conditions: Accessibility of the hospital Information: Availability of administration
Working conditions of staff information
Availability of equipment Availability of medical dossier
Qualified suppliers Availability of nursing dossier
Quality of incoming material Availability of patient dossier
Availability of updated documents
Technical Skilled staff Transfer of information
quality: Continuing education of staff
Availability criteria for emergency, Production Access time
rejection, relegation control: Waiting time
Availability of treatment and investigation Reporting time (time between
plan visit and report about visit)
Availability of supporting services and Systematic planning of visits
Availability of description of patients'
Relational Human treatment
quality: Complaints death with
Source: Sticthing Pace, 1994
[ 217]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
indicators, using the aforementioned cate-
gorisation (Table VI).
This framework was tested in the three
aforementioned case studies. In general the
framework could be used as a starting-point.
Nevertheless, in all cases the framework
needed adjustment to cope with the specific
situation. In the first case, only indicators
with respect to direct patients' contacts could
be taken into consideration. So, indicators
such as working conditions, job satisfaction,
equipment, incoming material were not
taken into consideration, nor were most
indicators with respect to technical quality,
accountability, co-operation, dossiers, re-
source occupancy level or resource utilisa-
tion rate.
In the second case the focus was on
patients who were already in the hospital and
were able to go to the after-care unit (by
ambulance). So, indicators like accessibility,
reachability by phone and incoming material
were not important for the hospital, but extra
emphasis was put on the transfer of infor-
mation from staff in the hospital to staff in
the nursing home. Moreover, specialists had
Figure 1
EFQM-model on total quality management
Table V
Performance indicators from the EFQM-model
Conditions: Accessibility Relational Treatment
Reachability by phone quality: Loyalty of clients
Facilities for relatives Complaints dealt with
Quality of incoming material Number and kind of complaints
Working conditions Percentage of clients not satisfied
Match of available and required after dealing with complaints
Job satisfaction Information: Information on services supplied
Absenteeism Information on patients' rights
Transfer of information
Technical Professionalism Production Access time
quality: Skills control: Waiting time
Continuing education Through-put time
Quality of the after-care
Unplanned recurrence of investigation
Arrangements for investigation, treatment
and after-care
Number of claims for liability
Source: European Foundation for Quality Management, 1995
[ 218]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
to be very explicit about the moment the
medical treatment was terminated. They had
to document the date that the treatment was
finished from a medical point of view (ac-
countability). Differences in facilities, equip-
ment and skills of the staff between the
hospital and the nursing home played an
important role as well and the right of the
patient to make a fair choice between hospi-
tal and nursing home (part of the perfor-
mance indicator human treatment). Finally,
the co-operation between hospital staff and
nursing home staff was very important.
In the third case (merger) the focus was on
the common intake and the tuning of activ-
ities in the health-care process. In the intake
stage the intake skills were considered im-
portant to make a good selection of patients.
The access time and processing time were
also considered important. For the tuning of
activities in the health-care process standar-
dised treatment and investigation pro-
grammes were formulated. An individual
treatment and investigation plan was de-
duced from one of these programmes. The
availability of dossiers at every stage of the
health-care process was considered impor-
tant too. Further emphasis was laid on
patient-related indicators such as human
treatment of patients by the staff, dealing
with complaints, transfer of information and
on indicators like professionalism and effec-
tiveness. Except for privacy, conditions were
not considered important.
Measurement tools
In the previous section a framework of
performance indicators for health-care pro-
cesses has been described. However, strictly
seen these indicators do not satisfy the
conditions of our definition of an indicator as
defined in section 2. Measurement tools and
related scales are required. In this section we
will present some of the measurement tools
for the aforementioned indicators. A re-
quirement for the first case was that patients
should be troubled as little as possible by the
collecting of data for the measurement of the
indicators. We used this as a starting-point
for the development of measurement tools.
We will provide a rough sketch of the
measurement tools per category of indicators
in the framework.
As regards the category of conditions the
following procedure for measurement can be
followed. The accessibility, the facilities, and
the privacy can be ``inspected'' by a so-called
patient panel, a group of four or five patients
or members of a platform for patients' rights.
The frequency of these inspections can be
limited to once every one to two years. In The
Netherlands the reachability by phone can be
measured by the telephone company. Mea-
surements are performed once a year during
one week and are sent to the hospital. The
working conditions, job satisfaction, and
equipment status can be measured by a
survey among staff. In The Netherlands such
surveys have been developed as a conse-
quence of a reviewed Factories Act. As a rule
measurements are executed on a 5-point scale.
Finally, the quality of the incoming material
can be measured by a random sample from
the material. This can be executed by the
quality department. Sampling plans need not
be developed, since these are available, as for
instance in the ISO 2859 standards (Interna-
tional Standardisation Organisation, 1989).
For the indicators with respect to technical
quality, peer reviews seem an appropriate
instrument. For the indicators professional-
ism, skilled staff, effectiveness and (quality
Table VI
Framework of performance indicators for health-care processes
Conditions: Accessibility Relational Human treatment
Reachability by phone quality: Loyalty of clients
Working conditions Complaints dealt with
Job satisfaction Accountability
Facilities/privacy Co-operation
Incoming material Information: Transfer of administrative information
Transfer of medical information
Technical Professionalism Dossiers
quality: Skilled staff
Safety Production Access time
Effectiveness control: Waiting time
Treatment and investigation plan Processing time
Resource occupancy level
Resource utilisation rate
Deduced from through-put time, access time and waiting time
[ 219]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
of) treatment and investigation plan, only
experts in the same field can give a profound
and sound judgement. As for safety, it might
be possible to ask patients and staff for
unsafe situations. In one of the cases check-
lists were developed for patients and staff.
Nevertheless, in our view a peer judgement
would be more appropriate. Peer reviews can
be executed once every four or five years.
Despite our restriction of causing patients
as little trouble as possible in the collecting of
data, it is inevitable in our view to ask for the
patients' opinion regarding the indicators
with respect to relational quality. Human
treatment, loyalty of clients, and how com-
plaints are dealt with can best be measured
by a survey among patients. In the first case
we developed a survey among out-patients.
The divisions holding out-patients clinics
were divided into three parts: surgical, non-
surgical, and others. In each group 80 sur-
veys are annually distributed among pa-
tients. If the results indicate an unacceptable
situation, the same survey is performed
separately for each division. The indicators
accountability and co-operation cannot be
measured by the aforementioned survey.
These indicators could be part of the peer
With respect to the category of informa-
tion, several measurement tools are re-
quired. The transfer of patient-related
information (to the patients) can be mea-
sured by the type of survey mentioned before.
In the survey a distinction should be made
between administrative data and medical
data. As regards the transfer of information
from one staff member contributing to the
care process of the patient to another staff
member contributing to the next phase of the
patient's process, another survey might be
useful. However, in our experience problems
regarding the transfer of information can
easily be traced when descriptions of the
health-care process are made (including the
information flows), with an active involve-
ment of the different disciplines in the
health-care process. In our view, this is a
more straightforward way than via a survey.
The availability of dossiers can be observed
once a year, for instance, by a member of the
quality department. Of course the quality of
the dossiers cannot be judged in this way; for
this purpose a peer review is more appro-
The indicators regarding production con-
trol can best be registered by administrative
staff. The most important measurements
should take place at the out-patient depart-
ment. For each division and clinic type
monthly statistics should be available on the
mean access time, waiting time, and
processing time. The actual duration of the
access time can easily be registered by
looking at the interval it takes to make an
appointment for a patient. Measuring the
waiting time and processing time used to be a
painstaking and labour-intensive task, with
handwritten timings to be registered on
forms. Currently, experiments are carried
out with a badge per patient and a built-in
chip. In this way values are automatically
registered in the computer system. Monthly
statistics on mean resource occupancy levels
and resource utilisation rates should be
annually available for each clinic and speci-
alty in the out-patients department.
In Table VII the results of this section are
Concluding remarks
In this paper a framework of performance
indicators and related measurement tools
has been presented. The development of the
framework was initiated by three case stu-
dies with process-related assignments in
different hospital settings. The case studies
provided a first test setting for the frame-
work. The performance indicators are (clo-
sely) related to the health-care process, so the
framework is a basis for monitoring health-
care processes.
The performance indicators can be
grouped into five categories:
1 conditions for processes;
2 technical quality of processes;
3 relational quality in processes;
4 information, supporting processes;
5 production control, managing the logistics
of processes.
The placement of some indicators in the
category of conditions is more or less arbi-
trary. In the other categories there is a
considerable correspondence between the
references used, although similar indicators
have different names in different references.
For the category of technical quality no
detailed outcome indicators were considered,
since these are strongly dependent on the
specific situation or the category of patients.
Four different measurement tools were
presented to make the performance indica-
tors operational. The measurement tools
were elaborated to different stakeholders in
the health-care process.
Of course the framework of indicators and
related measurement tools needs further
testing in practice. In the three case studies
the framework appeared to be useful as a
starting-point for a more specific elaboration
tailored to the case.
[ 220]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221
We hope that the combination of a theoretical
framework, mainly based on a literature
review, combined with practical elaboration
of tools, will contribute to the discussion on
performance indicators in health care.
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Stichting PACE (1994), Proefproject PACE-Kwali-
teitsborgingsnormen, TNO, Leiden (in Dutch).
Table VII
Measurement tools regarding indicators for health-care processes
Observation Accessibility Survey Working conditions
(patient panel) Facilities (staff members): Job satisfaction
Privacy Equipment (information transfer
(staff to staff))
(quality Incoming materials
department): Dossier (patients): Human treatment
Loyalty of clients
Peer review: Professionalism Complaints dealt with
Skilled staff Information transfer (to patient)
Effectiveness Registration Access time
Treatment and investigation plan (by hand): Resource occupancy level
Accountability Resource utilisation rate
(by chip/ Waiting time
computer) Processing time
Reachability by phone
[ 221]
J.D. van der Bij and
J.M.H. Vissers
Monitoring health-care
processes: a framework for
performance indicators
International Journal of Health
Care Quality Assurance
12/5 [1999] 214221