Selection of Key Financial Indicators: A Literature, Panel and Survey Approach
Since 1998, most hospitals in Ontario have voluntarily participated in one of the largest publicly available performance-reporting initiatives in the world. The project is led by the Hospital Report Research Collaborative (HRRC), a group of over 30 researchers who conduct research and engage Ontario hospitals in performance measurement activities. The HRRC has three objectives: (1) to improve the quality of care provided by Ontario's hospitals, (2) to enhance hospital accountability and (3) to conduct research into the determinants of good performance in healthcare. Over 20 reports have been produced to date, including acute care, emergency department care, complex continuing care, rehabilitation, mental health, nursing and women's health.
In the first issue of Hospital Reportin 1998, indicators of financial performance and condition were selected by a relatively ad hoc method, reflecting the newness of performance measurement at a system level in Canada. These indicators were used in subsequent issues of Hospital Report, with only minor additions and changes. In 2005-2006, the financial performance and condition indicators included in Hospital Report underwent a substantial redevelopment to reflect changes in the hospital industry, the data collected and performance criteria.
This article describes the method used to select key financial indicators for inclusion in Hospital Report. We describe the literature, panel and survey approach that was used, and we present the results for five years of recent data for Ontario hospitals.
The approach used to select the key financial indicators is depicted in Figure 1.
Step 1: Convening of an Expert Panel
From the outset, the HRRC team sought to ground the research in practical financial management. To this end, an expert panel was selected to provide practical advice on the selection and use of financial indicators for acute care hospitals. Fifteen individuals with a valuable mix of expertise and geographic perspective - and who are knowledgeable about acute care financial and operational issues, data and reporting practices - agreed to serve on the expert panel. Throughout the indicator redevelopment process, the expert panel provided practical advice on numerous methodological issues, including timeliness, accuracy, completeness and relevance of data; potential indicators of financial performance and condition; selection of financial indicators to be produced using secondary data; precise definitions of selected indicators, including account codes; reliability of data; face validity of data analyses; and interpretation of results and data limitations.
Step 2: Review of First Principles
The HRRC has been developing, measuring and reporting indicators of performance for Ontario hospitals since 1997 based on its First Principles, which provide guidance about the design and selection of indicators for quadrants and sectors in Hospital Report (Figure 2). The purpose of the principles is to encourage use of rigorous research and development processes and to increase coherence and consistency among indicators. They are not requirements but, rather, a set of criteria that teams can use to test whether existing indicators should be retained and to select new indicators. These principles were reviewed by the expert panel and guided the selection process.
Step 3: Selection of Dimensions of Financial Performance
Selecting dimensions of financial performance provided an overarching structure for identification of relevant financial indicators. Different financial indicators measure different dimensions of financial performance, such as profitability and liquidity, and all this information is needed to make an informed judgment about the financial health of an organization. For example, financial viability indicators may indicate an organization has a surplus, but liquidity indicators may show it is having difficulty paying its bills and capital structure indicators may show a large increase in debt.
Various dimensions of financial performance were identified from the five top-selling textbooks on healthcare financial management, which appear in Table 1. In the end, the expert panel decided to retain the current dimensions of financial performance and condition:
- Financial viability indicators measure the ability to generate the financial resources required to replace assets, acquire new technology and meet increases in service demands.
- Liquidity indicators measure the ability to meet cash obligations in a timely manner.
- Capital indicators measure the ability to meet long-term debt obli- gations and how capital assets (equipment) are being maintained.
- Efficiency indicators measure the ability to provide services at the expected cost and to minimize admini- strative costs.
- Human resources indicators measure the effectiveness of human resource management and practices.
Step 4: Review of Literature
A non-systematic literature review was undertaken to identify the financial indicators included in articles in peer-reviewed journals, industry publications and articles in practitioner journals that had been found to be important measures of hospital financial performance. To identify indicators in peer-reviewed articles, searches of Medline and other academic databases were undertaken using keywords such as hospital, financial performance and ratio analysis. Articles published prior to 1990 were excluded from the searches because of their likely lower relevance. Indicators were selected from the articles if results showed that they were statistically significant in explaining a dimension of hospital financial performance, such as profitability or financial distress. To identify indicators in industry publications, the Web sites of various commercial suppliers and industry organizations were reviewed. Finally, to identify indicators in practitioner journal articles, searches of various databases including these journals using the keywords above were undertaken. Due to the lack of statistical analysis in these articles, judgment of the project staff was used in selection of indicators. In total, 114 indicators were identified in the peer-reviewed journals, industry publications and articles in practitioner journals. The bibliography lists all the articles and publications in which the 114 indicators were found.
Among the 114 indicators found to be or deemed to be important measures of hospital financial performance, some were used in many articles and some were used in only one article. Identification of the most frequently used indicators was considered to be a logical way of reducing the opportunity set of indicators from 114 to a more manageable number. All publications and the indicators used in them were recorded and coded in a database. The database was then queried to count the articles that found a particular indicator to be important. An indicator was defined as frequently used if it appeared in five or more articles and infrequently used if it appeared in four or fewer articles. On this basis, 37 indicators were identified as frequently used and 77 identified as infrequently used.
To assess the extent to which the 37 frequently used indicators identified in the literature review measured different dimensions of financial performance, each indicator was assigned to one of the five dimensions listed in Step 3. Table 2 shows the five dimensions of financial performance, the indicators included under each dimension, a definition of each indicator and the frequency of the indicator in the articles identified in the literature review.
Step 5: Selection of the Indicators
Two weeks prior to convening, the expert panel was asked to complete and return to the research team an evaluation of the current Hospital Report indicators using three criteria:
- Validity: Can the indicator be accurately calculated? Are there signi- ficant reporting variations in the data elements used to calculate the indicator? Will there be confidence in the indicator?
- Importance: Will a change in the indicator be considered to be a material change in financial performance and condition? Will hospitals pay attention to the indicator? Will poor performance on the indicator be of significant concern?
- Usefulness: Can benchmarks be developed for the indicator? Will the indicator be used to improve financial performance and condition?
Prior to convening, the expert panel was provided with an information package that included a project work plan, the five performance dimensions, literature review, a list and definitions of the 37 most frequently used indicators in the literature, a form for evaluating the 37 indicators and a form for defining the account codes needed to calculate each indicator.
The research team and the expert panel met in Toronto on November 28, 2005. The evaluation of the current Hospital Report indicators by the expert panel was presented as a starting point for discussion. Each of the 37 most frequently used indicators in the literature and several potential nursing indicators identified in focus groups with nursing executives were discussed. Finally, some expert panel members suggested additional indicators for consideration.
Each of the 37 most frequently used indicators in the literature and the new nursing indicators was evaluated using the same criteria as were used for the current Hospital Report indicators: validity, importance and usefulness. After extensive debate and consideration, the expert panel made the following indicator selections:
- Current Hospital Report indicators. Seven of the current 12 Hospital Report indicators were retained (total margin, current ratio, unit cost performance, per cent corporate services, per cent equipment expense, in-patient nursing productivity and per cent registered nursing hours).
- Literature review. One new indicator from the literature review was selected (debt service coverage). Both total margin and current ratio (retained from the current Hospital Report) were also among the 37 most frequently used indicators from the literature review.
- Expert panel suggestions. One new indicator was suggested by the expert panel (per cent sick time).
The final performance dimensions, indicator names and indicator definitions are shown in Table 3. The nine indicators are fairly evenly distributed across the five performance dimensions, with the exception of the human resources dimension, in which there are relatively more indicators assigned. Despite an absence in the literature review, the panel decided the importance of human resources to the financial health of a hospital made it important to include such measures.
Step 6: Definition of Indicators by Account Numbers
A subgroup met immediately after the expert panel to define each indicator using account numbers specified by the Ontario Healthcare Reporting Standards (a comprehensive multi-year database of financial and statistical information describing the activities of Ontario hospitals). Carefully thinking about the precise definition of each indicator and the appropriate accounts to include in the numerator and denominator was simple for some indicators, such as the current ratio, and complicated for others, such as per cent sick time. (The numerator and denominator accounts can be downloaded from the 2006 Acute Care Technical Report at www.hospitalreport.ca.)
Step 7: Analysis of Data
The research team developed a com-puter program that produces and analyzes the indicator values for individual hospitals. Descriptive statistics, histograms and scatterplots were used to verify programming accuracy. After probable programming errors were eliminated, results showed that there were some obvious data quality problems, such as reporting of long-term debt as a long-term liability, but no current portion of long-term debt as a current liability. From a theoretical standpoint, these numbers were highly unlikely or impossible and reaffirmed an objective of the research team since the beginning of the project - to improve data quality.
When a potential data error was identified, the indicator value for the hospital was not reported and a note about the potential error was inserted. In this way, it was hoped that the hospital would be made aware of the potential data problem and would initiate corrective action so that the error would not appear in future indicator values.
Throughout the data analysis, the expert panel was consulted. Several teleconference calls were held to discuss the validity of the indicator definitions, outliers and data-quality problems. After resolution of these problems, the expert panel reviewed the data analysis, including tabular and graphical presentation of values for each indicator.
Step 8: Feedback and Revision
In January 2006, all acute care hospitals participating in Hospital Report were mailed a package with three documents - a letter from the Canadian Institute for Health Information explaining the redevelopment study, indicator values specifically for their hospital and an evaluation form. The evaluation form asked hospitals to provide feedback about the validity, importance and usefulness of the new indicators using the same scale as that used by the expert panel in their deliberations.
Forty-nine evaluations were re-turned, which was a response rate of 48%. In general, results showed that the number of people who rated the indicators as somewhat or very feasible, important or useful was greater than the number who rated the indicators as somewhat or very unfeasible, unimportant or not useful. Many comments about the indicators were also provided by respondents. All comments from the evaluations were categorized and their content analyzed in a report that was distributed and reviewed by the expert panel. As a consequence, changes in the account definitions were made to three of the indicators. Revised indicator values were calculated and circulated to hospitals for verification in April 2006. The comments and suggestions received from hospitals were extremely valuable because they identified several inconsistencies that required fixing and several improvements.
Indicator medians for all Ontario hospitals for 2000-2001 to 2004-2005 are shown in Table 4. A small amount of the year-to-year variation may be due to minor changes in the number of hospitals for which the medians are calculated, as shown in the bottom line of the table. Indicator medians by type of Ontario hospital for 2004-2005 are shown in Table 5.
Total margin measures the control of expenses relative to revenues as a per cent. Table 4 shows that, on average, Ontario hospitals achieved relatively low levels of financial viability during the five-year study period. Table 5 shows that during the most recent year in the study, community hospitals actually had a negative total margin while teaching and small hospitals had small positive total margins. In 2005, Ontario hospitals were surveyed to create benchmark values for the total margin; it was concluded that a hospital is demonstrating good financial management if the total margin is between 0% and 5% (Pink et al. 2005). Table 5 shows that, on average, small and teaching hospitals were within the benchmarks but that community hospitals were below the benchmark.
Current ratio measures the number of times short-term obligations can be paid using short-term assets. Table 4 shows that, on average, Ontario hospitals experienced declining liquidity during the five-year study period. Table 5 shows that during the most recent year of the study, community and teaching hospitals actually had current ratios less than 1.0, while small hospitals had a current ratio of 2.0. In 2005, Ontario hospitals were surveyed to create benchmark values for current ratio; it was concluded that a hospital is demonstrating good financial management if current ratio is between 1.0 and 2.0 (Pink et al. 2005). Table 5 shows that, on average, small hospitals were within the benchmarks but community and teaching hospitals were below the benchmark.
Debt service coverage measures the ability to pay obligations related to long-term debt - principal payments and interest expense. Table 4 shows that, on average, Ontario hospitals experienced a declining ability to service debt during the five-year study period. During the most recent year of the study, small hospitals had the highest and teaching hospitals had the lowest debt service coverage (see Table 5). Per cent equipment expense mea-sures how much of the total expenses is spent to acquire and operate computer systems, radiography machines and other capital equipment. Table 4 shows that, on average, equipment spending by Ontario hospitals was relatively constant during the five-year study period. As shown in Table 5, during the most recent year of the study, small hospitals had the highest and teaching hospitals the lowest per cent equipment expense.
Unit cost performance measures the extent to which a hospital's actual cost per equivalent weighted case differs from its expected cost. On average, unit cost performance of Ontario hospitals was relatively constant during the five-year study period (see Table 4). This is to be expected because the indicator values are regression coefficients for which the median is always close to zero. During the most recent year of the study, small and community hospitals had negative unit cost performance values, and teaching hospitals had a positive value (see Table 5). Per cent corporate services measures how much of total expenses is spent on administrative, finance, human resources and systems support. Table 4 shows that, on average, spending on corporate services of Ontario hospitals was relatively constant during the five-year study period. However, during the most recent year of the study, small hospitals had the highest and community hospitals the lowest per cent cor- porate services (see Table 5).
Per cent sick time measures the proportion of full-time patient care personnel hours that were paid sick hours. Table 4 shows that, on average, sick time of staff in Ontario hospitals was relatively constant during the three-year study period. As shown in Table 5, during the most recent year of the study, small hospitals had the lowest and teaching hospitals the highest per cent sick time. In-patient nursing productivity measures the proportion of nursing worked hours (including purchased service hours) for direct patient care. Table 4 shows that, on average, in-patient nursing productivity of Ontario hospitals was relatively constant during the five-year study period. During the most recent year of the study, small hospitals had the lowest and teaching hospitals the highest in-patient nursing productivity (see Table 5). Finally, per cent registered nurse hours measures the proportion of nursing care hours provided by registered nurses. As seen in Table 4, on average, the proportion of care provided by registered nurses in Ontario hospitals increased slightly during the five-year study period. During the most recent year of the study, small hospitals had the lowest and teaching hospitals the highest per cent registered nurse hours (see Table 5).
The redevelopment of the financial performance and condition quadrant in Hospital Report attempted to use a more systematic and evidence-based approach to the selection of key financial indicators. In our opinion, the approach reaffirmed the value of collaboration between a university-based team with research skills and practitioners with experience in the financial management of acute care hospitals. Together both parties worked to produce key financial indicators that boards and management can use to improve the financial management of their organizations.
Several conclusions can be drawn from comparison of a literature, panel and survey approach to the ad hoc approach used in the original Hospital Report. First, the literature, panel and survey approach selected seven indicators that the ad hoc approach had selected, eliminated five indicators that the ad hoc approach had selected and selected two indicators that the ad hoc approach had not selected. Thus, some indicators were affirmed, some were eliminated and some new indicators were selected. The bottom line is that the literature, panel and survey approach selected a set of key financial indicators that differed substantially from the set selected by the ad hoc approach.
Second, the literature, panel and survey approach selected some indicators that have been shown in many studies to be important in explaining hospital financial management, but it also selected some indicators for which there is little evidence. Perhaps this reflects differences in the financial management of Canadian hospitals, government funding methods and incentives, the supply of health human resources or all of the above. In any case, the literature alone provided an insufficient basis to select key financial indicators.
Third, a residual concern is data quality. Although management information systems (MIS) data have been collected for over a decade, there remain reporting variations and other data-quality concerns that affect the validity of the indicators. It is hoped that continued dissemination of indicators that use MIS data will make hospitals aware of data-quality problems and lead to better data in the future.
Future work includes developing benchmarks. In 2005, benchmarks were developed for total margin and current ratio by a survey of hospitals (Pink et al. 2005). Development of benchmarks for the other seven indicators will be in the 2006-2007 work plan of the HRRC finance team.
About the Author(s)
George H. Pink, PhD, is an associate professor in the Department of Health Policy and Administration, University of North Carolina at Chapel Hill, North Carolina.
Imtiaz Daniel, MHSc, CMA is a research associate with Hospital Report Research Collaborative, Waterloo, Ontario.
Linda McGillis Hall, PhD, is an associate professor in the Faculty of Nursing, The University of Toronto, Toronto, Ontario.
Ian McKillop, PhD, is the JW Graham Research Chair in Health Information Systems and an associate professor in the David R Cheriton School of Computer Science and Department of Health Studies and Gerontology, The University of Waterloo, Waterloo, Ontario.
AcknowledgmentThe authors acknowledge the helpful comments of Anyk Glussich of the Canadian Institute for Health Information.
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