International Journal of Healthcare Management

ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: http://www.tandfonline.com/loi/yjhm20

Hospital performance management: A multi-

criteria decision-making approach

Aman Tyagi & Preetvanti Singh

To cite this article: Aman Tyagi & Preetvanti Singh (2017): Hospital performance management:
A multi-criteria decision-making approach, International Journal of Healthcare Management, DOI:
10.1080/20479700.2017.1337606

To link to this article: http://dx.doi.org/10.1080/20479700.2017.1337606

Published online: 13 Jun 2017.

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INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT, 2017
https://doi.org/10.1080/20479700.2017.1337606

Hospital performance management: A multi-criteria decision-making approach

Aman Tyagi and Preetvanti Singh
Department of Physics and Computer Science, Faculty of Science Dayalbagh Educational Institute Dayalbagh, Agra, India

ABSTRACT ARTICLE HISTORY

The power of hospital performance management (HPM) today is recognized for providing Received 6 February 2017
effective healthcare quality. HPM is a key for any healthcare organization. It bridges the gap Accepted 30 May 2017
between conceptual planning of organizational goals and the physical monitoring of the
KEYWORDS
status of daily operations. The main aim of this research study is to identify and prioritize Multi-criteria decision-
performance indicators responsible for HPM. These indicators are evaluated using the making; hospital
MFFDH methodology. These indicators helped in generating scenarios and action plan for performance management;
enhancing HPM. performance indicators;
strategies

1. Introduction
The overall goal of a healthcare system is achieving
good health for the population, ensuring that health
services are responsive to the public, and ensuring
fair payment systems. A hospital has a central role in
achieving these goals. Emphasis should be put on the
development of systems monitoring the performance
of health care providers especially the hospitals. The
challenge for hospitals is to provide quality care for
enhanced patient satisfaction while achieving this at
lower costs and higher efficiencies. Hospital perform-
ance management (HPM) allows management to
identify areas for performance improvements, plan sys-
tematic performance improvement initiatives, set tar-
gets, and continuously track metrics. The challenging
issue of HPM requires a system that can help managers
make effective decisions to increase the hospital
performance.
Researchers have analysed different measures for
HPM like developing a performance measurement
for strategic performance management at a clinic [1];
developing a model that links long-term service
choices, intermediate operations decisions, and hospi-
tal performance [2]; describing checklists as an impor-
tant tool for error management and performance
improvement [3]; estimating hospital-level quality
indicators [4]; discussing how hospital mortality rates
can be used to judge hospital performance [5]; explor-
ing an association between hospital leadership and
quality by identifying signatures of high-performing
hospital boards and management practice [6]. The
above discussion reveals that HPM is multi-dimen-
sional in nature and thus multiple-criteria decision-
making (MCDM) tools can be applied in this area.
MCDM is concerned with structuring and solving
decision and planning problems involving multiple cri-
teria. The MCDM problem deals with the evaluation of
a set of alternatives in terms of a set of decision criteria.
Different tools for multi-criteria decision-making have
been applied in the area of health care. Analytical hier-
archy process (AHP), a MCDM tool, has been used for
evaluating the performance of the medical records
departments in some hospitals of Isfahan [7]; designing
performance condition indicator tree in gynaecology
and obstetrics ward [8]; and identifying hospitals’ key
performance indicators (KPIs) that provide an oppor-
tunity for health stakeholders to identify critical and
problematic points with lower costs as well as time
[9]. Other MCDM methods are also applied for evalu-
ation of the hospital performance, for example priori-
tizing the medical equipment for replacement [10];
evaluating organizational performance of hospital for
identifying the most appropriate hospitals [11]; rank-
ing factors of hospital information system to increase
physician’s performance of decision-making [12].
Measures were described for service quality in hospitals
using the AHP and analytic network process-based
SERVQUAL scale [13]. Geographical information sys-
tem was integrated with AHP for analyzing geographi-
cal accessibility of neurosurgical emergency hospitals
in Sapporo city [14]. A KPI, based on a unified scale,
was provided for the comparison of the performance
of different hospital buildings [15]. Five dimensions
of SERVQUAL were considered to develop strategy
for hospital service quality [16].
In this paper, a MCDM tool is used to identify and
prioritize the indicators responsible for HPM. The
organization of the paper is as follows: Section ‘The

CONTACT Aman Tyagi amantyagi_2009@live.in Department of Physics and Computer Science, Faculty of Science Dayalbagh Educational Institute
Dayalbagh, Agra 282005, India
© 2017 Informa UK Limited, trading as Taylor & Francis Group
2 A. TYAGI AND P. SINGH

Table 1. Linguistic variables and triangular fuzzy numbers for This ranking is then converted to the triangular
rating. L
fuzzy numbers, t̃ i,kj , (Table 1) for L levels, k respondent
Linguistic variables Triangular fuzzy numbers
Very Low (VL) (1, 1, 3)
teams, j number of respondents in each of the four
Low (L) (1, 2, 3) teams and i factors.
Medium Low (ML) (2, 3, 4) Step 4: Calculation of Respondent Fuzzy Perform-
Medium (M) (4, 5, 6) L
Medium High (MH) (6, 7, 8) ance Score (J̃ i )
High (H) (7, 8, 9)
L
Very High (VH) (8, 9, 9) From the t̃ i,kj , Aggregate Fuzzy Ranking ãLi,k is com-
puted using Equation (1):

multi-criteria futuristic fuzzy decision hierarchy meth-  1/J

J
L
odology’ of the paper gives a brief overview of the ãLi,k = t̃ i,kj , for every i (1)
methodology. Section ‘Evaluating the factors to j=1
enhance the performance of a hospital’ presents the
L
application of the methodology for HPM. Section Next the Respondent Fuzzy Performance Score J̃ i is
‘Results and discussion’ is devoted to results and calculated using:
discussion. ⎛ ⎞
⎜ SLi1 SLi2 SLi3 ⎟ ⎟
J̃ i = ⎜
L
⎝ , , ⎠ (2)
2. The multi-criteria futuristic fuzzy decision p
L

p
L

p
L
hierarchy methodology Si3 Si2 Si1
i=1 i=1 i=1

The multi-criteria futuristic fuzzy decision hierarchy

where
(MFFDH) methodology [17] is a multi-criteria
decision-making methodology that contains reasoning,  1/K
L

K
knowledge and the expert experience in the field, sup- S̃i = (Ik ⊗ ãLi,k ) (3)
ported by simple mathematics that enables the decision k=1
maker to weigh tangible and intangible criteria against
each other. MFFDH Methodology is an effective tool Step 5: Performing comparative judgment of the par-
for dealing with complex decision-making, helping ameters by Expert Group to get the Experts Opinions
the decision maker to set priorities and make the best and generating Expert Fuzzy Pair wise Comparison
decision. By reducing complex decisions to a series of Matrix
pairwise comparisons, and then synthesizing the A Fuzzy Pair wise Comparison Questionnaire is pre-
results, the methodology helps to capture both subjec- pared for Expert Group to rate and rank the parameters
tive and objective aspects of a decision. It also checks using Fuzzy Evaluation Scale (Table 2).
the consistency of the decision maker’s evaluations, These matrices are used to generate Expert Fuzzy
L
thus reducing the bias in the decision-making process. Pair wise Comparison Matrix, X̃ = [x̃Lmn ]
Following are the step of the methodology: Step 6: Calculating Expert Fuzzy Decision Weights
Step 1: Selection of Expert Group and Interdisciplin- L
(G̃i )
ary Respondent (IR) Group from different geographical L
Expert Fuzzy Decision Weights G̃i are computed
regions and related fields. using
The three Multi-Functional Core Groups, around
⎛ ⎞
which the MFFDH methodology revolves, are: Judg-
ment Making Group, Expert Group and IR Group. ⎜ vi1
L L
vi2 L ⎟
vi3
G̃i = ⎜ ⎟
L
⎝ , , ⎠ (4)
The Judgment Making Group is the core Group p
L

p
L

p
L
that interacts with the other two Groups and com- vi3 vi2 vi1
i=1 i=1 i=1
putes Global Futuristic Judgment (GFJ) Weights to
generate Scenarios and Action Plan for the formu- where
lated Goal.
 p 1/p
Step 2: Dividing the IR Group into 4 or 5 teams based

on their locations or knowledge skills and computing ṽLi = x̃Lmn , for i, m = 1, 2, . . . . . . , p, (5)
Respondent Importance Weights (Ik ), here k is the num- n=1

ber of teams. L
Step 7: Computing Fuzzy Judgment Weights (F̃ i )
Step 3: Rating and ranking of identified parameters L
by the IR Group. Fuzzy Judgment Weights F̃ i are calculated by taking
L L
A Modified Delphi Questionnaire is developed for the average of J̃ i and G̃i
IR Group to rate and rank the factors by using the lin- Step 8: Determining Crisp value of Fuzzy Judgment
guistic variables (Table 1) to achieve the Goal. Weights
 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3

Table 2. Fuzzy evaluation scale.

Relative importance Fuzzy scale Definition
1̃ (1,1,1) if diagonal Equally important
(1, 1, 3) otherwise
2̃ (2 – Δ, 2, 2 + Δa) Intermediate values between two adjacent judgments
4̃ (4 – Δ, 4, 4 + Δ)
6̃ (6 – Δ, 6, 6 + Δ)
8̃ (8 – Δ, 8, 8 + Δ)
3̃ (3 – Δ, 3, 3 + Δ) Moderately more important
5̃ (5 – Δ, 5, 5 + Δ) Strongly more important
7̃ (7 – Δ, 7, 7 + Δ) Very strongly more important
9̃ (9 – Δ, 9, 9 + Δ) Extremely more important
1/x̃ (1/x̃ + D, 1/x̃, 1/x̃ − D) If criterion i has one of the above assigned to it when compared with criterion j, then j has
the reciprocal value when compared with i

Table 3. Description of the dimensions and sub-dimensions of hospital performance.

Dimensions Description Sub-dimensions
Clinical A performance dimension, wherein a hospital, in line with the current state of knowledge, . Conformity of processes of care
effectiveness appropriately and competently delivers clinical care or services to, and achieves desired . Appropriateness of care
outcomes for all patients likely to benefit most . Outcomes of processes of care
. Effective Hospital Services

Efficiency Is a hospital’s optimal use of inputs to yield maximal outputs, given its available resources . Appropriateness of services
. Input related to outputs of care for
best possible care
. Use of available technology

Staff orientation Is the degree to which hospital staff are appropriately qualified to deliver required patient . Practice environment
care, have the opportunity for continued learning and training, work in positively . Recognition of individual needs
enabling conditions, and are satisfied with their work . Health promotion activities
. Safety initiatives
. Behavioural responses and health
status

Responsive Is the degree to which a hospital is responsive to community needs, ensures care continuity
governance and coordination, promotes health, is innovative, and provides care to all citizens
irrespective of racial, physical, cultural, social, demographic or economic characteristics
Safety A performance dimension, wherein a hospital has the appropriate structure, and uses care . Patient safety
delivery processes that measurably prevent or reduce harm or risk to patients, healthcare . Staff safety
providers and the environment . Environment safety

Patient A dimension of performance wherein a hospital places patients at the centre of care and
centredness service delivery by paying particular attention to patients’ and their families’ needs,
expectations, autonomy, access to hospital support networks, communication,
confidentiality, dignity, choice of provider, and desire for prompt, timely care

L
Crisp value of Fuzzy Judgment Weights F̃ i is calcu- compute Normalized Futuristic Judgment Weights NiL
lated using Equation (6) L
fa,b (F̃ i )
NiL =  L (8)
L
Cl,r = [ga (FilL ), ga (FirL )] (6) fa,b (F̃ i )

where Step 10: Computing Global Futuristic Judgment

ga (FilL ) = [(Fi2L − Fi1L )a + Fi1L ] represents the left (GFJ) Weights
L
value of a-cut for F̃ i , and GFJ Weights are computed for all levels from com-
ga (FirL ) = [Fi3L − (Fi3L − Fi2L )a] represents the right puted Normalized Futuristic Judgment Weights and
L generating Scenarios and Action Plan for the Goal.
value of a-cut for F̃ i .
Step 9: Calculating Normalized Futuristic Judgment
Weights (NiL )
The Decision Weights are calculated using Equation
(7) 3. Evaluating the factors to enhance the
performance of a hospital
L
fa,b (F̃ i ) = [b ga (FilL ) + (1 − b)ga (FirL )], The hospitals are important part of the public health
(7)
0 ≤ b ≤ 1, 0 ≤ a ≤ 1 care reform process. In this section, the MFFDH meth-
odology is applied to identify and prioritize the per-
which are then normalized using Equation (8) to formance indicators (PI) for effective HPM.
4 A. TYAGI AND P. SINGH

Table 4. PI with GFJ Weights. Expert Group members were then asked to per-
PIs GFJ Weights form pairwise comparison of the PIs at every level.
Clinical effectiveness 0.3186 This rating and ranking was used to compute the
Efficiency 0.1992 L
Staff orientation 0.3010 Expert Fuzzy Decision Weights G̃i using Equations
Responsive governance 0.0336 (4) and (5). The Decision Weights were calculated
Safety 0.0864
Patient centredness 0.0612
using Equations (6) and (7) which were then normal-
ized using Equation (8).
Finally, GFJ Weights WiL were calculated for all
The Goal of the Research Study is to compute levels using the Principle of Hierarchic Composition.
GFJ Weights for identifying the most important par- This computation is done in MS Excel.
ameters responsible for enhancing the hospital
performance.
Three experienced, dynamic and research oriented
members formed the Judgment Making Group. The 4. Results and discussion
Expert Group consisted of 17 medical experts and the Table 4 and Figure 1 summaries the result and reveals
IR Group consisted of 72 members from different geo- the following findings:
graphical locations.
The PIs for achieving the Goal were identified by
- Clinical Effectiveness is the most weighted PI for
interviewing the experts and referring to the literature.
HPM. To achieve the clinical efficiency, attention
Description of the dimensions and sub-dimensions of
should be paid on enhancing the Hospital Services,
hospital performance is given in Table 3.
assuring Conformity of processes of care, and
The IR group members were divided into four teams
Appropriateness of care
R1, R2, R3, and R4. The four teams were ranked to
- Next important PI is Staff Orientation, for which
determine their knowledge levels. Computed Respon-
Behavioural responses and health status, Practice
dent Importance Weights Ik for the four teams are:
environment and Safety initiatives are considered
R1 0.490 important
R2 0.187 - Also, attention should be given on Efficiency to yield
R3 0.140 maximal outputs.
R4 0.183
The IR Group rated and ranked the identified PIs,
which were converted to the triangular fuzzy numbers The generated scenario and action plan based on
L these prioritized PIs are:
t̃ i,kj . Next the Respondent Fuzzy Performance Scores
were computed using Equations (1)–(3). Clinical efficiency can be enhanced by:

Figure 1. The prioritized sub-dimensions.


➢ Shared Governance: as it allows nurses to partici-
pate in the decision-making process of strategies
and initiatives that affect their practice.
➢ Reducing heath care-related errors: by creating a
system to reduce for example adverse medication
events, or to reduce healthcare associated infections.
➢ Promoting effective coordination of care: by redu-
cing gaps and duplications in patient care delivery
through e-prescribing or telemedicine.
➢ Training future health care practitioners: for
example, for the specialized trainee, such as infec-
tious diseases specialist in training, concentrated
exposure to the microbiology laboratory may be
accommodated on site or at a distant location.
Safety can be enhanced by:
➢ Developing clear policies and protocols for patient
safety aligned with national guidelines and organ-
izational objectives.
➢ Providing regular communication on patient
safety initiatives.
➢ Encouraging transparency through a non-punitive
system for tracking errors and near-misses.
➢ Making sure patient safety projects are well
defined with appropriate parameters and targets.
➢ Supporting and implementing patient safety edu-
cation for staff, physicians, patients and families.
5. Conclusion
The MFFDH methodology is a multi-criteria decision-
making methodology that can be used in any domain
for prioritizing the factors or indicators. The present
study proposes the application of this methodology
for development of a strategic performance manage-
ment system. The main advantage of the method is
that it considers both tangible and intangible factors,
and also deals with uncertainty.
The main objective of the study is to compute GFJ
Weights for identifying the most important parameters
responsible for enhancing the hospital performance.
This further will help in focusing on the issues related
to HPM.
Disclosure statement
No potential conflict of interest was reported by the authors.
Contributors: None.
Ethics approval: None.
Funding
One of the authors Aman Tyagi is thankful to University
Grants Commission, New Delhi for financial support.
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5
Notes on contributors
Aman Tyagi did his M. Tech. in Computer Science from
Dayalbagh Educational Institute Agra (India). Currently he
is working for his Ph.D. degree in the Department of Physics
and Computer Science, D.E.I., Agra. His area of interest
includes biomedical engineering, decision support system,
fuzzy rule base system and intelligent systems.
Preetvanti Singh is a Professor in the Department of Physics
and Computer Science, Dayalbagh Educational Institute,
Agra, India. She received her PhD in Operation Research
from Dayalbagh Educational Institute, Agra, India. Her current
research interests include decision support system (DSS), geo-
graphical information system (GIS) and optimization tech-
niques. She has published several papers in various reputed
journals and co-authored computer science textbooks.
ORCID
Aman Tyagi http://orcid.org/0000-0002-7607-1302
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