THE PRODUCTIVE
MANAGEMENT
METHODOLOGY FOR
HEALTHCARE SERVICES
(PMMHS) VIRTUAL
COURSE
Angela Gomez, Ph.D.
Belize
July 28-30, 2015
Purpose of the Course
To develop and/or or improve the
management information system for
decision-making in health care facilities
or health services networks by
implementing the Productive
Management Methodology for Health
Services and its supporting tools.
Educational Objectives
• To recognize the general concepts and actions of the PMMHS that
accompany the development or strengthening of a health
management information system to allow the attainment of data
required for efficient and timely decision-making.
• To analyse the current status of management information systems in
health facilities or health services networks and their capacity for
supporting managerial decision-making.
• To identify the elements needed to develop or strengthen health
management information systems in health care facilities or health
services networks using production, efficiency, costs and quality
indicators.
• To apply the elements of a health management information system to
managerial decision-making aimed at the continuous improvement of
the health care facility or health services network.
Context for PMMHS
Macro
Level
National Health
Authorities
Mid Level
Directors of Networks,
Hospitals, Health Centres
and other health services
Micro Level
Adapted from Vicente Ortún Rubio
Providers of direct healthcare
services and Service Coordinators
Course Road Map
Costs
Indicators
Production
Theoretical
Foundation
•Universal Coverage
•Primary Health Care
•Integrated Health
Services Delivery
Networks
•PMMHS
•Production Centres
•Services
•Distribution of
Services
•Types of Indicators
•Standardization of
Indicators
•Data Collection
•Types of Costs
•Distribution of
Costs
•Analysis
Universal Coverage
Primary Health Care
Integrated Network of Healthcare Services
Productive Management Methodology for
Healthcare Services (PMMHS)
MODULE 1:
THEORETICAL
FOUNDATIONS
Universal Access to Health
and Universal Health Coverage:
Imply that all people and communities
have access, without any kind of
discrimination, to comprehensive,
appropriate and timely quality health
services, without exposing users to
financial difficulties.
Values:
Right to Health
 Equity
 Solidarity
Alma Ata of the XXI century – Health for All
Universal access
to health and
universal health
coverage are the
foundation of an
equitable health
system.
Four Simultaneous and Interdependent Strategic
Lines
SL1: Expanding equitable access to comprehensive, quality,
people and community centered health services
• Move forward in providing universal access to
comprehensive and progressively expanded health
services.
• Identify the unmet and differentiated health needs of the
population, as well as the specific ones of groups in
situation of vulnerability.
• Improve and increase the response capacity at the first
level of care articulated in IHSNs.
• Improve human resource capacity in the first level of care
by increasing employment opportunities, particularly in
underserved areas.
SL2: Strengthening stewardship and governance
• Define and implement a set of actions to strengthen the
stewardship and governance of the health sector (i.e.
public health functions, legal and regulatory framework).
• Establish and/or strengthen formal mechanisms of social
participation and accountability.
• Establish national targets and goals, and define their plans
of action, set priorities for the 2014-2019 period.
SL3: Increasing and improving financing, with equity
and efficiency, advancing toward the elimination of
direct payments
•
•
•
Increase public financing of health (6% of GDP a
useful benchmark).
Allocate resources on a priority basis to the primary
level of care
Improve the efficiency of financing and health
system organization:
• Transparent and consolidated procurement mechanisms.
• Changes in the model of care prioritizing promotion and prevention, quality of
services.
•
Advance toward eliminating direct payment that
constitutes a barrier to access, replacing it by
pooling-mechanisms based on solidarity.
SL4: Strengthening intersectoral coordination to
address social determinants of health
• Exercise leadership to impact policies,
plans, regulations and actions beyond
the health sector that address the social
determinants of health.
Examples of multisectoral policies
•
Social protection
•
Vector control
•
Food industry regulation
•
Promotion of physical activity
•
Workers health
•
Environmental contamination
•
Environmental protection
•
Regulation of the pharmaceutical industry
•
Regulation of alcohol consumption whilst driving
•
Regulation of vehicles and road safety
• Implement plans, programs and
projects to facilitate the empowerment
of people and communities.
World Health Report 2008
PHC reforms necessary to refocus health systems towards health for all
Source: World Health Report 2008
PHC
“A renewed strategy on PHC is an
essentially condition for achieving
international development goals,
such as those contained in the
United Nations Millennium
Declaration, and addressing the
fundamental determinants of health
– as defined by the WHO
Commission on the Social
Determinants of Health – and to
codify health as a human right, as
articulated by some national
constitution , civil society groups
and others.”
( PAHO, March 2007)
What is the PHC-based Framework?
Social & Moral
Political & Administrative
3 Core
Values
7 Principles
13 Elements
Framework
Pan American Health Organization
Structural &
Functional
Integrated Health Services Delivery Networks
“ a network of organizations that provides, or makes
arrangements to provide, equitable, comprehensive,
integrated and continuous health services to a defined
population and is willing to be held accountable for its
clinical and economic outcomes and the health status of
the population served.”
( Modified from Shortell, SM; Anderson DA; Gillies, PR; Mitchell JB; Morgan, KL. Building integrated systems: the
holographic organization. Healthcare Forum Journal 1993; 36(2): 20-6).
Attributes of Integrated Health Services
Delivery Networks
• Given the wide range of health system context, there is not a
single organizational model for IHSDNs; there are multiple
possible models.
• The public policy objective is to achieve a design that meets
each system’s specific organizational needs.
• Despite the diversity of contexts in different countries, the
experience accumulated in recent years indicates that
IHSDNs require some essential attributes for proper
performance.
What is PMMHS?
• It is a methodology for the management of health services based
on production, efficiency, resources and costs (PERC), the quality of
services and user satisfaction;
• It is a tool to aid managers in decision-making and guiding
institutional changes;
• It entails a participatory style of management;
• It helps in the development of indicators to evaluate challenges
that threaten the productive capacity and resource utilization of
health services;
• It facilitates monitoring and negotiation of network agreements;
and
• It has a software (PERC) and a set of tools that support the
methodology.
Productive Management Methodology for
Health Systems (PMMHS)
• PMMHS is a methodology developed by PAHO to respond to new
approaches and emerging practices in the management of health services
and, in its new version, is aimed at organization and optimal management
of health services in the transformation to PHC-based health systems.
• It provides elements for the analysis of relevance, efficiency, and quality of
health care provision, the negotiation and control of management
agreements and can assist in the building of an institutional culture of cost
rationalization and maximization of social productivity.
• It is a useful management tool to generate an institutional and managerial
culture in public administration based on productivity, transparency and
accountability.
Principal Objectives of the Productive Management
Methodology for Health Services (PMMHS)
• Information-based decisionmaking
• Efficient management of health
resources
• Improved access to quality of
services
The PMMHS View of Health Service Systems
Health services are productive
processes that can be evaluated
with quantitative measures of
equity, efficacy, and efficiency.
Service systems can be organized as
production centres and sub-centres
according to their products,
resources utilized and their
associated costs.
The Goal of PMMHS is Evidence-based Health
Service Management
Determining the right mix of
services and procedures by which
available resources can provide
the greatest benefit to the
population at the lowest possible
risk and cost.
Muir Gray JA (2004): Evidence-based Healthcare. How to
Make Health Policy and Management Decisions.
PMMHS View Of Healthcare Services
Three key elements:
1. Demand for services:
determine by the needs,
expectations and preferences
of the population being
served;
2. Productive capacity:
determined by the
infrastructure and the
available resources (human
and technical); and
3. Final production: the end
results (outputs) of the
services provided.
PRODUCTIVE MANAGEMENT
METHODOLOGY FOR HEALTH
SERVICES (PMMHS)
It is offered as a useful tool to generate
an information culture in health services
management based on productivity,
transparency, and accountability.
Management Applications of the PMMHS
BUDGETING
PLANNIN
G
COST
ANALYSIS
QUALITY
MANAGEMENT
PMMHS
MACRO &
MICRO
ANAYLYSES
PRODUCTIVITY
ANALYSIS
HIRING
ANALYSIS
Production Centres
Services
Distribution of Services
MODULE 2:
PRODUCTION
A Production Centre…
is a physical and/or functional group
of activities that independently, or
in a clearly defined manner,
consume resources in the
production of a good or service.
In healthcare organizations
what is typically considered
a SERVICE unit is often a
production centre
Production Centres
Production
Centre
Identification
of Human
Resources
Identification
of Supplies &
Materials
Identification
of General
Expenses
Identification
of
Production &
Distribution
Identificati
on of
Revenues
&
Billing
Outpatient
Clinics/Unit
Yes
Yes
Yes
Yes
Yes
Promotion &
Prevention
Yes
Yes
Yes
Yes
Yes
Emergency
Yes
Yes
Yes
Yes
Yes
Hospitalization
Yes
Yes
Yes
Yes
Yes
Pharmacy
Yes
Yes
Yes
Yes
Yes
Laboratory
Yes
Yes
Yes
Yes
Yes
Rehabilitation
Yes
Yes
Yes
Yes
Ye
Radiology
Yes
Yes
Yes
Yes
Yes
Nutrition
Yes
Yes
Yes
Yes
Yes
Services might be disaggregated for further analysis,
for example, promotion & prevention services
Production
Centres
Identification
of Human
Resources
Identification
of Supplies &
Materials
Identification
of General
Expenses
Identification Identification
of Production of Revenue &
&
Billing
Distribution
Hypertension
Program
Yes
No
Yes
Yes
Yes
Diabetes
Program
Yes
No
Yes
Yes
Yes
Cancer
Prevention
Program
Yes
No
Yes
Yes
Yes
Maternal &
Infant
Yes
Yes
Yes
Yes
Yes
Yes
yes
Yes
Yes
Yes
Program
Family
planning
Program
For Primary Health Care modeled systems, it is recommended that promotion
& prevention activities are disaggregated as much as possible:
PRODUCTION
CENTRE
Identification of
Human Resources
Identification of
Supplies & Materials
Identification of
General Expenses
Identification of
Production &
Distribution
Identification of
Revenue & Billing
Oral Health
Yes
Yes
Yes
Yes
Yes
Newborn Care
Yes
Yes
Yes
Yes
Yes
Family Planning
Yes
Yes
Yes
Yes
Yes
Growth &
Development
Yes
Yes
Yes
Yes
Yes
Adult Care
Yes
Yes
Yes
Yes
Yes
Cancer
Yes
Yes
Yes
Yes
Yes
Hypertension
Yes
Yes
Yes
Yes
Yes
Diabetes
Yes
Yes
Yes
Yes
Yes
Vaccination
Yes
Yes
Yes
Yes
Yes
Other programs
Yes
Yes
Yes
Yes
Yes
Distribution of Support Services to Final Services
Healthcare
EMERGENCY
Discharges
BDO
HOSPITALIZATION
Consultation
OUTPATIENT
CLINIC
Activities
PROMOTION
&
PREVENTION
Tests
LABORATORY
Studies
X RAYS
Expedition
PHARMACY
STRATEGIC ACTIVITIES
Production Centres with Strategic Activities
STRATEGIC
PLATFORM
PLANNING
ASSESSMENT
OF CLIENT
NEEDS
QUALITY CONTROL
MARKETING
SAFETY
MANAGEMENT
SUSTAINABLE
DEVELOPMENT
These activities can be grouped in one production centre called
Management
Production Centres Data Gathering
An efficient data collection tool should…
•
•
•
not be too burdensome for service providers
be user-friendly and accessible to any team member
permit everyone to use it to identify information errors
The successful use of information gathering tools for each production
centre depends on…
• The collaborative effort of the managers of the information system and of
the production centre
However, one person should be assigned
to be responsible for data input
Types of Indicators
Standardization of Indicators
Data Collection
MODULE 3:
INDICATORS
Indicators are data that reflect a specific situation or
particular condition in a given time or period and are
often expressed as statistical data, i.e., percentages,
rates, etc.
http://www.oect.es/portal/site/Observa
torio/menuitem.
What indicators should be used?
In PMMHS indicators are classified as…
Structural Indicators
These measure the physical and institutional
conditions in which services are provided.
Process Indicators
These measure actions that result in good service
delivery. They reflect the steps, events or actions at
play in service delivery and represent any contact
between clients (demand) and service providers
(supply).
Results Indicators
These monitor what happens to clients following the
service delivery process and measure the effects of
the service delivery in the development of clients and
the population at large.
Example of standardization of Indicators
Structure Indicators
NAME
Days bed availability
MEASURING UNIT
Days
OPERATIONAL UNIT
Number of beds × days in the period
GOAL
By service
FREQUENCY
Monthly
SOURCE OF INFORMATION
Medical Records or Statistics
Department
RESPONSIBLE FOR DATA COLLECTION
Head/Supervisor of Nursing Services
RESPONSIBLE FOR DATA PROCESSING
Head of Medical Records or Statistics
Department
RESPONSIBLE FOR DATA ANALYSIS
Management Team
VISUALIZATION
Table of absolute numbers
Example of standardization of Indicators
Process Indicators
NAME
Occupancy Rate
MEASURING UNIT
Percentage
OPERATIONAL UNIT
(Number of occupied bed days/number
of available bed days) × 100
GOAL
95%
FREQUENCY
Monthly
SOURCE OF INFORMATION
Daily Census
RESPONSIBLE FOR DATA COLLECTION
Head/Supervisor of Nursing Services
RESPONSIBLE FOR DATA PROCESSING
Head of Medical Records or Statistics
Department
RESPONSIBLE FOR DATA ANALYSIS
Management Team
VISUALIZATION
Line graph
Example of standardization of Indicators
Results Indicators
NAME
Waiting Time for Outpatient Visit
Appointment
MEASURING UNIT
Days
OPERATIONAL UNIT
Sum of appointments assigned by date
minus date of request
GOAL
• General medicine less than 2 days
• Specialty less than 5 days
FREQUENCY
Monthly
SOURCE OF INFORMATION
Appointment management system
RESPONSIBLE FOR DATA COLLECTION
Medical Records/Outpatient Services
RESPONSIBLE FOR DATA PROCESSING
Coordinator of Outpatient Services
RESPONSIBLE FOR DATA ANALYSIS
Management Team
VISUALIZATION
Trend graph
Healthcare Impact Indicators
Healthcare Impact
Indicators reflect the
impact of
management decisions
on the quality of care
and safety
Financially-based
decisions, such as
one to contain
costs, are financially
beneficial
• They should not, however, be
permitted to have a negative effect
on the quality of care
• Nor diminish the safety of
healthcare services
Supply Indicators
Identifying the consumption of supplies
is an essential task which serves as an
indicator of the dynamic production of
the services.
There are many kinds of supply
indicators, such as the following
examples:
Supply Indicator: Hospital Beds
So we establish a clear
picture of the bed
supply for the services
offered by the hospital
by determining:
• the distribution of beds in
percentages and
• the total beds per service
Another Supply Indicator is Human
Resources
This indicator provides a view of the personnel hours
allocated for each service, such as:
• Outpatient services
• Services that result in hospitalization
• Administrative hours, allocated
by apportioning the total number of
professional hours among the services
This will give us a picture of the
distribution of hours
Once the indicators are defined and their structure is recorded in the design
file the data collection tools must be defined.
The data collection instrument can be
developed to capture information from the
various softwares used by the institution or
manually. What is important is the
collection of the required data.
Types of Costs
Distribution of Costs
Analysis
MODULE 4: COSTS
“COST ARE THE
RESOURCES MEASURED
IN MONETARY TERMS
THAT ARE NEEDED IN
ORDER TO PRODUCE OR
PROVIDE A SERVICE.”③
Expenses relate to any other outlay,
different from the costs, which can be
administrative, sales related, and
financial expenses ④
③ R i ncón d e P a r r a, H a yd eé . C a li dad , P r od u ct ividad y C os t os : a ná li s i s d e r ela ci ones ent r e es t os t r es
concept os . Act u a li dad C ont a ble F a ces , E ner o, a ño/ v ol. 4 , nú m er o 0 0 4 U ni v er s i dad d e los And es . Mer i d a
Venez u ela ( r ev i s t a @f aces. ula.v e) 2 0 0 1. P a g e. 5 7 .
④ . G AR C ÍA, OSC AR L E ÓN Ad m inis t ración f i na nci er a: f u nd a ment os y a pli ca ci ones .. t er cer a ed i ci ón.
P r ens a Mod er na E d i t or es . C a li , C olom bi a . P á g i na 15 8
Direct and Indirect costs
When building a chair the amount of wood and metal (direct
materials) used can be clearly and precisely determined as well as the
hours it took to build it (direct labour), while it would be difficult and
costly trying to calculate with some level of precision the amount of
time spent by the supervisor (indirect labour), the amount of
lubricants used for the maintenance of the equipment (indirect
material), the electricity used, the depreciation, and the taxes (other
indirect production costs) spent for every unit produced considering
the indirect relationship that exists between those items with the
product they are part of ⑧.
DIRECT MATERIAL + DIRECT LABOUR + INDIRECT PRODUCTION COSTS = PRODUCT
COST
COSTS
Variable
Costs
Total
Costs
Fixed Costs
Fixed
Costs
PRODUCTION
TOTAL COSTS = FIXED COST + VARIABLE COST
⑦ RINCON, CARLOS AUGUSTO Y VILLAREAL, FERNANDO. Costos: Decisiones empresariales. Ecoe Ediciones. Bogotá, 2009.
Classification of cost by consumption location
LABOUR
Human effort applied to the production of a product or
service. It could be direct or indirect
DIRECT LABOUR
It is the labour force physically related with the
production process of a product or service
INDIRECT LABOUR FORCE
It is a located in the organization but cannot be
reasonably associated to the production process
because it is not physically related to the service-delivery
process
RAW MATERIAL
These are the materials or supplies used in the
production process of the services that are being
provided. They could be direct or indirect
DIRECT RAW MATERIAL
These are the raw material that are directly related to
the product, either by allocation or due to the relevance
of their value
INDIRECT RAW MATERIAL
These are the raw material that have no direct relation
with the product and their allocation to the unit of
production is complex
⑨. RINCON, CARLOS AUGUSTO Y VILLAREAL, FERNANDO. Costos: Decisiones
empresariales. Ecoe Ediciones. Bogotá, 2009.
Classification of costs by consumption location
MATERIALS
DIRECT
INDIRECT
DIRECT
PRODUCTION
MATERIALSDPM
PERSONNEL
DIRECT
INDIRECT
DIRECT LABORDL
EXTERNAL
SERVICES
DIRECT
OTHER COSTS
INDIRECT
DIRECT
SERVICES - DS
INDIRECT
PRODUCTION
COSTS- IPC
PRIME COST
It is the combination of direct production costs.
⑨. RINCON, CARLOS AUGUSTO Y VILLAREAL, FERNANDO. Costos: Decisiones empresariales. Ecoe Ediciones. Bogotá, 2009.
Distribution of Costs
LF
Assign the elements of cost: labor
force, supplies and materials, and
general expenses to each of the
production centres, which are
defined as final services
and
support services.
This distribution lets you come up
with the total cost for each of the
production centres.
The total cost of the production
centres consists of the direct and
indirect costs of the final services
and the products. The total cost of
a final service of the production
centre becomes its direct cost and
the total cost of the support
services allocated, the indirect
cost.
SM
GE
LF
SM
GE
LF
SM
GE
FINAL
SERVICES
OPERATIVE
SUPPORT
SERVICES
ADMINISTRATIVE
SUPPORT
SERVICES
TOTAL COST OF
PRODUCTION CENTRE
TOTAL COST OF
PRODUCTION CENTRE
TOTAL COST OF
PRODUCTION CENTRE
DIRECT COST OF
FINAL SERVICES
INDIRECT COST OF
FINAL SERVICES
TOTAL COST
OF FINAL
SERVICES
COST PER
PRODUCT
Analysis
Interventions aimed at identifying, analyzing and decreasing management
gaps must seek to creating a balance between PRODUCTION, EFFICIENCY,
RESOURCES and COSTS
They involve the . . .
• Utilization of adequate information
• Analysis of problems
• Definition of goals
• Evidence-based decision-making
• Monitoring of results
The relationship between these three process create three potential
gaps:
DEFICIT IN THE MANAGEMENT CAPACITY
Between the productive capacity and the final production
INSTITUTIONAL DEFICIT
Between the final production and users’ demand
DEFICIT OF RESPONSE CAPACITY
Between the productive capacity and the users’ demand
Overall Benefits of PMMHS
PMMHS…
• Evaluates the performance of institutions, programs and
healthcare services delivery networks
• Identifies the most relevant factor or problems related to the
institution’s productivity profile
• Facilitates the analysis of these factors or problems in order to
define change options
A premise of the PMMHS is that
making informed decisions leads
to the optimization of production
and the rational use of resources
in order to improve access to and
the quality of healthcare
Factors that Determine a Successful
Implementation of the PMMHS
• High level political support
• Management leadership
• Administrative support
• Sustainable financial support
• Training of health service managers for the development of new
skills
• Active participation of the implementation team
• Access to needed information
• Constant support and monitoring
• Information platform
• Basic information tools
• Internet access
A Tour of the Virtual
Classroom…
VIRTUAL CAMPUS
FOR PUBLIC HEALTH
Virtual Campus for
Public Health
http://cursos.campusvirtuals
p.org/?lang=en