CAN THE BALANCED SCORECARD TRANSFORM PUBLIC INSTITUTIONS?

A case study from the Mexican Institute of Social Security

August 2012

Franklin, Cory. A Healthy Skepticism about Electronic Medical Records. The Guardian. The Guardian, 23 April 2011. Web. 17 August 2012.

Goldstein, Jacob and Jane Zhang. Waste Feared in Digitizing Patient Records. The Wall Street Journal. The Wall Street Journal, 22 January 2009. Web. 17 August 2012.

Boseley, Sarah. Lords Question Readiness for Swine Flu Second Wave. The Guardian. The Guardian, 28 July 2009. Web. 17 August 2012.

OVERVIEW OF GLOBAL SPENDING ON HEALTH

HEALTH CARE SPENDING FACTS, 2004 Total global expenditure for health Total global expenditure for health per person per year: Country with highest total spending per person per year on health: Country with lowest total spending per person per year on health: Country with highest government spending per person per year on health: Country with lowest government spending per person per year on health: Country with highest annual out-of-pocket household spending on health: Country with lowest annual out-of-pocket household spending on health: Average amount spent per person per year on health in OECD countries: Percentage of the worlds population living in OECD countries: Percentage of the worlds total financial resources devoted to health spent in OECD countries: Annual spending by the municipal government of New York City (population 8.2 million) on health: Annual spending by the government of Bnin (population 8.2 million) on health: WHO estimate of minimum spending per person per year needed to provide basic, lifesaving services: Number of WHO Member States where health spendingincluding spending by government, households and the private sector and funds provided by external donors--is lower than US$50 per person per year: Number of WHO Member States where health spending is lower than US$20 per person per year: Percentage of funds spent on health in WHOs Africa Region provided by donors:
World Health Organization Fact Sheet No. 319 on health financing. February 2007.

US$ 4.1 trillion + US$ 639 United States (US$ 6,103) Burundi (US$ 2.90) Norway (US$ 4,508) Burundi (US$ 0.70) Switzerland (US$ 1,787) Solomon Islands (US$ 1.00) US$ 2,716 18% 80% US$ 429 million US$ 86 million US$ 35 to US$50 64

30 14%

WEALTH AND HEALTH OUTCOMES ARE CORRELATED

WEALTH AND HEALTH OUTCOMES, 2003

) 80 70 60 50 40 30 20 10 0 0 1,000 2,000 3,000 4,000 Total expenditure on health per capita (US Dollars) 5,000 6,000

Life expectancy (number of years)

World Health Organization Fact Sheet No. 319 on health financing. February 2007.

THE MEXICAN INSTITUTE OF SOCIAL SECURITY

Founded in 1943, the Mexican Institute of Social Security (IMSS) is a federally autonomous agency that provides health and social security benefits to private sector workers. INSTITUTIONAL LINES OF SERVICE
COLLECTION INSURANCE Health risk management Administration of worker compensation Management of pensions Management of social benefits SERVICE PROVISION Medical services Day care services Vacation and sport centers Theaters and training centers

Collection and enrollment

The

worker contributions collected by IMSS amount to 2% of Mexicos Gross Domestic Product.

The Institute covers eight times

more in medical disability benefits than all of the nations private insurers as a whole.

The Institute has the largest

medical and social security infrastructure in the country.

IMSS is the nations second

largest tax collector after the Tax Revenue Administration Service (SAT).

It employs more than 400

thousand workers and provides 50% of the medical consultations and surgical procedures in the public sector.

OPERATIONAL MAGNITUDE
IMSS cares for more than 50 million users through 1,510 Family Medicine Units, 287 hospitals, and 1,459 day care centers, among others and it provides a significant share of services delivered within the National Health System (NHS). A TYPICAL DAY AT IMSS IN 2011 AND SHARE OF THE TOTAL HEALTH SERVICES DELIVERED IN 2009
Medical services Total IMSS users Population assigned to a Family Medicine Unit Population cared for through IMSS-Oportunidades Medical services Total consultations provided Family Medicine consultations Specialty consultations Dental consultations Emergency care Hospital discharges Surgical interventions Births attended Clinical tests Radio-diagnostic studies Other services Pensions paid on the last day of the month Daily care for children in day care centers Average number of collection and enrollment transactions Number of users Percent share of the 2011 population in 2011 58,293,160 50.82 47,405,653 41.33 10,887,507 9.49 National average in a Percent share of the total typical day of 2011 NHS productivity in 20091/ 60.7 470,814 46.8 326,609 38.6 77,359 29.4 18,335 63.6 48,511 38.7 5,456 43.8 4,075 48.1 1,268 52.3 721,834 54.4 53,721 2,789,125 199,232 300,000

CHALLENGES
Achieve improvements in health and satisfaction
41

USER DISSATISFACTION WITH MEDICAL SERVICES

Very or somewhat satisfied users (Dec 09): 77% 16 32 11 100

38,0

MATERNAL MORTALITY RATE PER 100,000 LIVE BIRTHS

30,1 30,2 34,0

High wait-times

Personnel insensitivity

Incomplete prescriptions

Others

Concerns

2000

2002

2006

2008

PRODUCTIVITY 2009

INTERNAL

Optimize internal management to meet demand

32,905

CONSULTS PER DOCTOR IN CONTACT WITH PATIENTS, 20091/

5,6 2.473
OECD Average

COMPLETELY FILLED PRESCRIPTIONS (percent of total prescriptions)

95,8
2006

44

2.296
IMSS

1.791
Mexico

96,9
2007

96,9
2008

Waitlisted patients

<30 min waitime Preventive per in ED curative consults

BEDS PER 1,000 USERS, 20091/

NURSES PER 1,000 USERS, 20091/

9,8 2,7
Latinamerica

Expand medical infrastructure and availability of personnel

MEDICAL SPECIALISTS IN CONTACT WITH PATIENTS PER 1,000 USERS, 20091/

1,8 1,3 0,6
IMSS

5,8

1,9

1,3
Mexico

0,8
IMSS OECD Average

2,4
Mexico

2,2
IMSS

OECD Latinamerica Average

OECD Average

Mexico

Secure the Institutes financial viability

AVERAGE SPENDING PER IMSS USER (USD)

377
2002

ANNUAL EFFICIENCY GAINS IN THE PROCUREMENT OF MEDICATION AND THERAPEUTIC GOODS (million USD)
475
2008

569
2008

861

2009

Economic cycle Epidemiologic and demographic transitions Women in the work force
1/The

EXTERNAL

USERS ENROLLED IN FAMILY MEDICINE USERS OVER 65 YEARS OF AGE, PROJECTION (percent of IMSS users) (thousands)
30.212 33.083 35.612 38.685 9
2004 2008 2012 2000

CAPACITY IN DAY CARE CENTERS

231.821

11

14

20 103.249
2025 2000

189.935

2000

2008

2015

2004

2008

OECD average does not include Mexico. Source: OECD Health Data 2009, PAHO, Secretariat of Health, and IMSS.

DESIGNING THE INSTITUTIONAL STRATEGY

The wrong strategy (the supermarket list): To deliver results within each strategic objective, the operational departments identified in 2008 more than 200 projects with 600 performance indicators that would amount to an additional expense of 2.5 billion USD.
DESIGNING AND IMPLEMENTING A WORK PROGRAM

DESIGNING THE INSTITUTIONAL STRATEGY

DEFINING STRATEGIC PROJECTS

Three guiding principles were

defined in order to address the Institutes primary challenges: i. Improve managerial and operational capacity ii. Strengthen the Institutes financial viability iii. Prepare IMSS for the creation of the Integrated Health Care System within each principle.

The

Strategic Planning Unit selected and prioritized 60 of these projects on the basis of: Relationship to the strategic objectives and guidelines Anticipated impact Financial feasibility Operational risks

The

20 of these were considered

priority projects for the General Direction. excellency.

Strategic objectives were targeted XX Key Performance Indicators

were defined to evaluate the impact of the institutional strategy.

48 strove to achieve operational

strategy, projects and organizational resources were aligned in a work program with assigned responsibilities, goals and timeframes that were communicated to both governance and operative structures. Monitoring and evaluation tools were created: Balanced Scorecard and business intelligence tools Strategic follow-up meetings Strategic follow-up reports

Nation-wide

implementation effectively began in September 2009.

THE BALANCED SCORECARD SUPPORTS THE MANAGEMENT MODEL NEEDED TO DELIVER RESULTS
In order to meet the institutional objectives, the Strategic Planning Unit depends on key factors for success :

Improving the Institutes managerial and operational capacity Strengthening the Institutes financial viability Preparing IMSS for the creation of the Integrated Health Care System

Communication of institutional strategy to organization

the the

SOCIAL IMPACT

Improve user satisfaction with the Institutes services Improve the quality and opportunity of care and attention

INTERNAL PROCESSES

Elimination of information silos between departments Definition of clear responsibilities and goals among leadership Establishment of a formal routine for monitoring and evaluating performance Refinement of metrics and targets based on progress made

Improve the efficiency in services provided Develop a health services market Promote the portability of rights and convergence of health care service Improve the administration of human resources and organization Train medical specialists Strengthen infrastructure Achieve a more efficient and transparent spending Strengthen sources of revenue Optimize the installed capacity

The Balanced Scorecard emphasizes these elements, fostering the directive insight necessary to deliver the strategic program

ADMINISTER FINANCIAL RESOURCES

LEARNING AND GROWTH

CLOSING GAPS IN INFRASTRUCTURE AND HUMAN RESOURCES IS CORRELATED WITH ADVANCES IN INTERNAL HOSPITAL PROCESSES
As a result of a strong procurement and collection strategy, IMSS achieved efficiencies of more than 3.75 billion USD between 2009 and 2011. These savings contributed to finance projects under the Learning and Growth perspective, achieving the acquisition of nearly 500 million USD in medical equipment, 15,000 new medical positions and 3,000 new hospital beds at the close of 2011. CORRELATION BETWEEN LEARNING AND GROWTH AND INTERNAL HOSPITAL PROCESS INDICES1/ (Indices, 2011)
100 GTO

HIGHLIGHTED PERFORMANCE ADVANCEMENTS (2009- 2011)

Internal Hospital Proceses index 2011

71.6% saturation of Emergency Department observation areas in general hospitals ( 8%) 471 patients in wait lists to receive elective surgery ( 99%) 30.6 kidney transplants per million IMSS users ( 25%)

90 80 70 60 50 40 30 20 10 0 0 AGS BCSDGO MOR TAB NAYZAC TAM OAX SLP

SON

NL

MICH

DFS BC

JAL EMO

CHIH COL YUC CHISVERS SIN HGO TLAX COAH QROO VERN EMP GRO CAMP QRO 20 40

DFN

PUE 60 80 100

Learning and Growth index 2011

1/The

Learning and Growth index includes an investment realized between 2009 and 2011 in new hospital beds, new medical positions, and medical equipment. The Internal Hospital Processes index is comprised of indicators relating to productivity and efficiency of the surgical process, occupation and extended wait times in Emergency Departments, accessibility to family medicine care, and medication supply. Both indices are normalized by taking standard deviations with respect to the average, and standardizing results between zero and 100, where 100 represents the maximum increase.

IN-HOSPITAL AND PREVENTION METRICS DEMONSTRATE A POSITIVE CORRELATION WITH IMPROVEMENTS IN QUALITY OF CARE MEASURES
The institutional strategy focuses on prevention as a means to improve quality of care and attention, while maximizing the Institutes financial and installed capacity. 8% reduction in the maternal mortality rate, which stood at 29.1 in 2011.
CORRELATION INTERNAL HOSPITAL PROCESSES AND HOSPITAL QUALITY INDICES1/ (Indices, 2011)
100

25% reduction in the cervical cancer mortality rate per 100,000 women aged 24 years or more.
CORRELATION INTERNAL PREVENTION PROCESSES AND QUALITY OF PREVENTIVE CARE INDICES2/ (Indices, 2011)
100 OAX EMP TAB HGO AGS BCS CHIS JAL ZAC COAH

Hospital Quality (Social Impact) index 2011

NAY

80 70 60 50 40 30 20 10 0 GRO EMP AGS OAX SON TAB BCS ZAC GTO

Index of the Quality of Preventive Care (Social Impact) 2011

90

90 80 70 60 50 40 30 20 10 0 0 20 40 TLAX SIN NAY GTO DGO

QROO

JAL MOR HGO VERN CHIS BC QROO SIN YUC QRO DFS MICH EMO DGO TAM CAMP DFN PUE CHIH VERS SLP COL NL TLAX COAH 0 20 40 60 80 100

DFN

VERN VERS YUC PUE CHIH

SON QRO EMO CAMP DFS MICH GRO TAM BC NL

SLP

MORCOL 60 80

100

Internal Hospital Processes index 2011

Internal Prevention Processes index 2011

1/ The 2/The

Hospital Quality index includes inpatient admissions as a proportion of total hospital admissions, as well as in-patient hospital mortality and maternal mortality rates. Internal Prevention Processes index is comprised of indicators relating to accessibility to family medicine care, and standards of service and coverage in preventive programs, PREVENIMSS and DIABETIMSS. The Quality of Preventive Care index includes maternal mortality, mortality due to cervical cancer, breast cancer and acute myocardial infarction. Indices are normalized by taking standard deviations with respect to the average, and standardizing results between zero and 100, where 100 represents the maximum increase.

IMSS DELEGATIONS WITH GREATER ADVANCES IN INTERNAL PROCESS MEASURES REGISTERED HIGHER USER SATISFACTION RESULTS
To effectively align the institutional strategy and address user needs, National Satisfaction Surveys were established in 2009 with the advice of the Mexican Chapter of Transparency International. The latest survey conducted demonstrates an improvement in two of the three concerns most frequently identified by IMSS users in the basal measurement performed in 2009. Reports on high wait times fell from 41 to 36%, likewise incompletely filled prescriptions saw a reduction of 11 to 8 %. Insensitivity on the part of IMSS personnel remains a challenge to be addressed, and is a topic targeted through projects aligned to both the Learning and Growth and Internal Processes perspectives. CORRELATION BETWEEN MEDICAL CARE INTERNAL PROCESSES AND SATISFACTION REPORTED BY USERS1/ (Percentage of satisfied users and Internal Process Index 2011)
Users reported being very or somewhat satisfied (Average July-December, 2011 percentage of all respondents)

HIGHLIGHTED PERFORMANCE ADVANCEMENTS (2009- 2011)

8 out of 10 IMSS users are satisfied or somewhat satisfied with the Institutes medical services ( 2%) An increase of one standard deviation in internal process indicators is expected to lead to an increase of approximately four percentage points in user satisfaction metrics. 99% satisfaction with day care centers ( 24%)

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 0 20 40 60 80 100 SIN BC NAY COL NL DGO GTO BCS

GRO MICH ZAC CHIH VERN TAB TAM VERS CHIS AGS SON JAL PUE YUC COAH MOR OAX SLP TLAX HGO EMO CAMP QRO DFN QROO DFS EMP

Medical Care Internal Processes index 2011

1/The

Medical Care Internal Processes index is comprised of indicators relating to productivity and efficiency of the surgical process, occupation and extended wait times in Emergency Departments, accessibility and standards of service in family medicine care, medication supply, and institutional response to user observations. The index is normalized by taking standard deviations with respect to the average, and standardizing results between zero and 100, where 100 represents the maximum increase.

FOR MORE INFORMATION ABOUT THIS CASE AND IMSS STRATEGY: JOSE LUIS ROMO CRUZ HEAD OF THE STRATEGY UNIT AND HEAD OF ADVISORS TO THE GENERAL DIRECTOR OF IMSS joseluis.romo@imss.gob.mx SARA ZETUNE CALDERON HEAD OF DIVISION OF STRATEGY IMSS sara.zetune@imss.gob.mx