What can be considered quality medical service? How can it be measured by the organization without violating treatment privacy? Does economical streamlining necessarily damage treatment and service quality? How can an entire organization be directed to achieve business objectives and at the same time maintain high medical standards and accomplishments?

Health organizations around the world are facing some significant challenges and a set of ever growing pressures. Technology and medicine development present Doctors with a wide variety of tools and methodologies for treatment. Alongside – the Internet, communications and information accessibility bring the public, being wiser and well informed consumers, to demand advanced medical treatment. This complexity intensifies in view of the need to work under strict budgetary constraints.
As consultants for many organizations going through performance analysis processes, we have come across a significant difference between business organizations and health organizations of any kind. The ultimate goal of business organizations is to promote financial revenues for the shareholders. Such organizations focus in their analysis, on results  - "the bottom line". Even process' measurement is aimed at promoting an internal streamlining that will eventually serve the financial profit issue. Health organizations, on the other hand, whether they are hospitals or HMOs, are obliged, first and foremost, to provide complete and quality medical service. The service provider cannot approach its customers with direct marketing campaigns, as commonly done in the banking and telecommunications sectors, due to privacy issues. The medical business, which is dealing with human lives, does not operate as merely a "business" (it's a good thing…), and is also operating under strict budget limitations. In Israel the government set the HMOs budgets based on number of insurers and the insured population characteristics. Thus, it is wrong to evaluate performance of health organizations by using only economical parameters, as done in many places.

In view of the above, the challenge which health organizations face and the tension between medical quality and budget are obvious. However, does this conflict prevent the provision of superb medicine in a limited budget? Fortunately for us, as health consumers, there is also an important connection between the two. It appears that quality medicine has a direct impact on costs reduction. By – reduced repeated hospitalizations and ineffectual complications, preventive medicine and early discovery of diseases reduce costs on one hand, and increase customers health and satisfaction from the system, on the other.

There are several approaches and methods for evaluating performance in organizations. The most common one used in the business sector is the Balanced Scorecard methodology. This methodology, which was developed more than a decade ago by Kaplan and Norton of Harvard, is gaining momentum in many applications in recent years. The methodology deals with weighted measurements in a number of perspectives: financial, customers, internal processes and learning & growth. Thus, the result of the evaluation is comprised of the entire organizational aspects, and is not focused on one aspect alone. This method emphasizes continuous measurement over time in order to achieve improvement in the measures. The methodology was adopted as the basis for measuring quality in medicine; however the traditional perspectives were replaced with ones more suitable to health organizations.

Ness-Gilon adjusted the application methodology we have developed for business organizations; to suit the special needs of the medical sector. Together with our customers we have created a number of guiding principles for the application process and definition of measures. Firstly, the definition of measure was performed by Doctors and staff members supported by administrations. The measures represent the organizational terminology, are clear and relevant at any time. Secondly, the measures were adjusted to all the organizational levels. Each of the measures was defined a quantify value for improvement, usually in comparison with the data of the same organizational unit, versus the entire organization's achievements in the present and past. The objectives are challenging but achievable, in order to achieve positive competition. Finally, the chosen measures for implementation were only the ones who were based on credible and reliable raw data. All measures are defined meticulously. This definition is the basis for organizational communications which is based on a single, unified organizational truth.

The first signs of medical measurement in Israel started some four years ago in the "Clalit Health Services", alongside the decentralization process of clinics in the community. In the scope of the "Bina" system, we have developed a model for medical measures that enabled the clinic's managers to promote prevention medicine. These measures improved Physicians' awareness and provided clinical information on patients who do not perform important routine check-ups, such as: Mammography, Diabetes follow-up etc. The focus on population at risk and early treatment reduced scope of diseases and increased treatment affectivity.
Progressing towards comprehensive and complete evaluation, using the Balanced Scorecard approach, was performed in the "Clalit" hospitals through a "wards self-management" project. In this project a set of tools and measures was developed for self-management of hospital wards. This project was awarded first prize in BI category in a competition done by "People and Computer" magazine. The judges of the competition emphasized that: "this project represents a breakthrough in the definition of advanced management, based on the assumption that a staff managing its own operations and performances – will achieve its goals, develop its capabilities and improve during time. In such culture the ward accepts increased responsibility of the required resources and their use, in order to fulfill its objectives".

In another medial center "Shiba", an innovative and large scoped project was performed based on a thorough field work done in cooperation with the clinical staffs to define medical measures and objectives for the various wards. Using common medical scales, enables analyses and evaluations, which take into account the impact of the ward's case-mix on the performance and outcome measures. This system integrates the patient data from the "medical production floor" with additional logistical data. In a scientific conference conducted in 2004 by the "Israeli Society for Quality Medicine", Dr. Weiss-Meilik, who led this project said "The system enables to have reciprocal managerial connections between the organizational units, wings level and management level with emphasis on vertical connection between all units in achieving the strategic objectives". Dr. Weiss-Meilik led the first project of its kind in the world, versus the different wards in "Shiba" hospital. Measures were defined for each ward, based on complex clinical algorithms, which enabled precise and quality measurement of medical outcomes and performances.

Adopting a systematic medical measurement, led to the launching of the HVA (Health Value Added) system in "Maccabi Health Services" HMO last year. Three perspectives were defined in the system: Medical quality, Perceived quality and Economical performance. The definition of the objectives was done by combined staffs in accordance to disease commonness, potential clinical damage, disease cost and improvement potential. Prof. Shuki Shemer CEO of "Maccabi", wrote in the HMO's recent Newsletter: "In order to achieve the highest medical quality, we have to be based on thorough and comprehensive measurement which is done continuously and during time". Maccabi implemented the system comprehensively and with full transparency to the Doctors in order to harness the entire organization to achieving the common objectives. Dr. Kukia, Head of Health Division said: "In order to use the measures as a managerial tool, the organization has to be equipped with the best computerized system that will enable it to develop decision support tools… the HVA teaches us that a brave confrontation with a problem which is a worldwide one – of how to improve the provided medical treatment to our insurers and at the same time maintain an economical balance and customer satisfaction – is the right way to achieve results".

Building computerized systems to support the organizational process was the starting point for significant organizational change. Implementing measurement in operational and management processes integrally, is significant to achieving the primary objectives of this process. Full management commitment, as in other organizational processes, is needed as a basis for success. Additional emphasis in the various implementation phases were: creating a constructive competition between the units in order to boost achievements, transparency of the statistical information to all levels, methodical measurement, continuous control over the input data quality, transforming objectives into measures and measuring improvement trends.

Measuring medical quality to achieve improvement, while meeting budget limitation is a first degree challenge. Health organizations in Israel proved, as world pioneers in this area, that measurement and improvement are possible in practice. The emphasis which these organizations put on quality – leads directly to improvement in the medical quality we receive as health consumers, while meeting the defined budget frame. Ness-Gilon is proud and happy for the privilege to be a true partner in this process. We hope that the success of these projects will be the basis for continuous improvement in the quality of medicine in Israel.