JoseLuisRomo_IMSS

7/30/2019 JoseLuisRomo_IMSS

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CAN THE BALANCED SCORECARD

TRANSFORM PUBLIC INSTITUTIONS?

A case study from the Mexican

Institute of Social Security

August 2012


2/15

Franklin, Cory. A Healthy Skepticism about

Electronic Medical Records. The Guardian. The

Guardian, 23 April 2011. Web. 17 August 2012.


3/15

Goldstein, Jacob and Jane Zhang.

Waste Feared in Digitizing Patient

Records. The Wall Street Journal.

The Wall Street Journal, 22 January2009. Web. 17 August 2012.


4/15

Boseley, Sarah. Lords Question Readiness for Swine Flu

Second Wave. The Guardian. The Guardian, 28 July 2009.

Web. 17 August 2012.


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Total global expenditure for health US$ 4.1 trillion +

Total global expenditure for health per person per year: US$ 639

Country with highest total spending per person per year on health: United States (US$ 6,103)Country with lowest total spending per person per year on health: Burundi (US$ 2.90)

Country with highest government spending per person per year on health: Norway (US$ 4,508)

Country with lowest government spending per person per year on health: Burundi (US$ 0.70)

Country with highest annual out-of-pocket household spending on health: Switzerland (US$ 1,787)

Country with lowest annual out-of-pocket household spending on health: Solomon Islands (US$ 1.00)

Average amount spent per person per year on health in OECD countries: US$ 2,716

Percentage of the worlds population living in OECD countries: 18%

Percentage of the worlds total financial resources devoted to health spent in OECD

countries:

80%

Annual spending by the municipal government of New York City (population 8.2 million)

on health:

US$ 429 million

Annual spending by the government of Bnin (population 8.2 million) on health: US$ 86 million

WHO estimate of minimum spending per person per year needed to provide basic, life-saving services:

US$ 35 to US$50

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:

64

Number of WHO Member States where health spending is lower than US$20 per person

per year:

30

Percentage of funds spent on health in WHOs Africa Region provided by donors: 14%

HEALTH CARE SPENDING FACTS, 2004

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

OVERVIEW OF GLOBAL SPENDING ON HEALTH


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WEALTH AND HEALTH OUTCOMES ARE CORRELATED

Lifeexpectancy(numberofyears)

Total expenditure on health per capita (US Dollars)

WEALTH AND HEALTH OUTCOMES, 2003

80

70

60

50

40

30

20

10

0

0 1,000 2,000 3,000 4,000 5,000 6,000

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


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COLLECTION

Health risk management

Administration of worker

compensation

Management of

pensions

Management of social

benefits

INSURANCE SERVICEPROVISION

The Institute covers eight timesmore in medical disability

benefits than all of the nations

private insurers as a whole.

The worker contributionscollected by IMSS amount to

2% of Mexicos Gross Domestic

Product.

IMSS is the nations second

largest tax collector after the

Tax Revenue Administration

Service (SAT).

Collection andenrollment

Medical services

Day care services

Vacation and sport

centers

Theaters and training

centers

THE MEXICAN INSTITUTE OF SOCIAL SECURITY

The Institute has the largestmedical and social security

infrastructure in the country.

It employs more than 400

thousand workers and provides

50% of the medical

consultations and surgical

procedures in the public sector.

INSTITUTIONAL LINES OF SERVICE

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.


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OPERATIONAL MAGNITUDE

Medical servicesNumber of users

2011

Percent share of the

population in 2011

Total IMSS users 58,293,160 50.82

Population assigned to a Family Medicine Unit 47,405,653 41.33

Population cared for through IMSS-Oportunidades 10,887,507 9.49

Medical servicesNational average in a

typical day of 2011

Percent share of the total

NHS productivity in 20091/

Total consultations provided 470,814 60.7

Family Medicine consultations 326,609 46.8

Specialty consultations 77,359 38.6

Dental consultations 18,335 29.4

Emergency care 48,511 63.6

Hospital discharges 5,456 38.7

Surgical interventions 4,075 43.8

Births attended 1,268 48.1

Clinical tests 721,834 52.3

Radio-diagnostic studies 53,721 54.4

Other services

Pensions paid on the last day of the month 2,789,125

Daily care for children in day care centers 199,232

Average number of collection and enrollment transactions 300,000

A TYPICAL DAY AT IMSS IN 2011 AND SHARE OF THE TOTAL HEALTH SERVICES DELIVERED IN 2009

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).


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4132 11 16 100

High wait-times Personnel

insensitivity

Incomplete

prescriptions

Others Concerns

CHALLENGES

AVERAGE SPENDING PER IMSS USER

(USD)

INTERNAL

EXTERNAL

Secure the

Institutes

financial viability

ANNUAL EFFICIENCY GAINS IN THE PROCUREMENTOF MEDICATION AND THERAPEUTIC GOODS

(million USD)

Expand medical

infrastructure

and availability

of personnel

USER DISSATISFACTION WITH MEDICAL SERVICES MATERNAL MORTALITY RATEPER 100,000 LIVE BIRTHS

USERS OVER 65 YEARS OF AGE, PROJECTION(percent of IMSS users)

Achieve

improvements in

health and

satisfaction

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

PATIENTS PER 1,000 USERS, 20091/

Economic cycle

Epidemiologic and

demographic

transitions

Women in the

work force

USERS ENROLLED IN FAMILY MEDICINE(thousands)

CAPACITY IN DAY CARE CENTERS

30.212 33.083 35.61238.685

2000 2004 2008 2012

9 1114

20

2000 2008 2015 2025

Very or somewhat satisfied users (Dec 09): 77%

Optimize

internal

management to

meet demand

475 861

2008 2009

1,81,3

0,6

OECD Average Mexico IMSS

NURSES PER 1,000 USERS, 20091/

9,82,7 2,4 2,2

OECD

Average

Latinamerica Mexico IMSS

5,81,9 1,3 0,8

OECD

Average

Latinamerica Mexico IMSS

95,896,9 96,9

2006 2007 2008

COMPLETELY FILLED PRESCRIPTIONS(percent of total prescriptions)

377

569

2002 2008

38,030,1 30,2 34,0

2000 2002 2006 2008

CONSULTS PER DOCTOR IN CONTACT WITHPATIENTS, 20091/

2.473 2.296 1.791

OECD Average IMSS Mexico

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

103.249189.935 231.821

2000 2004 2008

445,6

Waitlisted

patients


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DESIGNING THE INSTITUTIONAL STRATEGY

DESIGNING THE INSTITUTIONAL

STRATEGY

DEFINING STRATEGIC

PROJECTS

DESIGNING AND

IMPLEMENTING A

WORK PROGRAM

Three guiding principles were

defined in order to address theInstitutes 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

Strategic objectives were targeted

within each principle.

XX Key Performance Indicators

were defined to evaluate the

impact of the institutional strategy.

The Strategic Planning Unit

selected and prioritized 60 ofthese projects on the basis of:

Relationship to the strategic

objectives and guidelines

Anticipated impact

Financial feasibility

Operational risks

20 of these were considered

priority projects for the General

Direction.

48 strove to achieve operational

excellency.

The strategy, projects and

organizational resources werealigned 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 andbusiness intelligence tools

Strategic follow-up meetings

Strategic follow-up reports

Nation-wide implementationeffectively began in September

2009.

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.


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In order to meet the institutional

objectives, the Strategic PlanningUnit depends on key factors for

success :

Communication of the

institutional strategy to the

organization

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

The Balanced Scorecard emphasizes

these elements, fostering the

directive insight necessary to

deliver the strategic program

Improving theInstitutes managerial

and operational

capacity

Strengthening theInstitutes financial

viability

Preparing IMSS forthe creation of theIntegrated Health

Care System

Strengthen infrastructure

Train medical specialists

Improve the administration of human resources and organization

Improve the quality and opportunity of care and attention

Improve the efficiency in services provided

Promote the portability of rights and convergence of health care service

Strengthen sources of revenue

Achieve a more efficient and transparent spending

Improve user satisfaction with the Institutes services

Develop a health

services market

Optimize the installed capacity

SOCIAL

IMPACT

INTERNA

L

PROCESS

ES

LE

ARNING

AND

GROWTH

ADMINISTER

FINANCIAL

RESOURCES

THE BALANCED SCORECARD SUPPORTS THE MANAGEMENT MODEL NEEDED TO

DELIVER RESULTS


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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.

AGS

BC

BCS

CAMP

COAH

COL

CHIS

CHIH

DGO

GTO

GRO

HGO

JAL

EMO

EMP

MICHMOR

NAY

NL

OAX

PUE

QRO

QROO

SLP

SIN

SON

TABTAM

TLAX

VERN

VERSYUC

ZAC

DFN

DFS

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100

InternalHospitalProcesesindex2011

Learning and Growth index 2011

CORRELATION BETWEEN LEARNING AND GROWTH AND

INTERNAL HOSPITAL PROCESS INDICES1/

(Indices, 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 EmergencyDepartments, 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.

CLOSING GAPS IN INFRASTRUCTURE AND HUMAN RESOURCES IS CORRELATED WITH

ADVANCES IN INTERNAL HOSPITAL PROCESSES

HIGHLIGHTED PERFORMANCE ADVANCEMENTS

(2009- 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%)


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IN-HOSPITAL AND PREVENTION METRICS DEMONSTRATE A POSITIVE CORRELATION

WITH IMPROVEMENTS IN QUALITY OF CARE MEASURES

CORRELATION INTERNAL HOSPITAL PROCESSES AND

HOSPITAL QUALITY INDICES1/

(Indices, 2011)

1/ 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.2/The 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.

AGS

BC

BCS

CAMP

COAH

COL

CHIS

CHIH

DGO

GTO

GRO

HGOJAL

EMO

EMP

MICH

MOR

NAY

NL

OAX

PUE

QROQROO

SLP

SIN

SONTAB

TAM

TLAX

VERN

VERS

YUC

ZAC

DFN

DFS

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100

HospitalQuality(SocialImpact)

index2011

Internal Hospital Processes index 2011

AGS

BC

BCS

CAMP

COAH

COL

CHIS

CHIH

DGOGTO

GRO

HGO

JALEMO

EMP

MICH

MOR

NAY

NL

OAX

PUE

QRO

QROO

SLP

SINSON

TAB

TAM

TLAX VERN

VERSYUC

ZAC

DFN

DFS

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100

Indexofthe

QualityofPreventive

Care(So

cialImpact)2011

Internal Prevention Processes index 2011

CORRELATION INTERNAL PREVENTION PROCESSES AND

QUALITY OF PREVENTIVE CARE INDICES2/

(Indices, 2011)

8% reduction in the maternal mortality rate,

which stood at 29.1 in 2011.

The institutional strategy focuses on prevention as a means to improve quality of care and attention, while

maximizing the Institutes financial and installed capacity.

25% reduction in the cervical cancer mortality

rate per 100,000 women aged 24 years or more.


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IMSS DELEGATIONS WITH GREATER ADVANCES IN INTERNAL PROCESS MEASURES

REGISTERED HIGHER USER SATISFACTION RESULTS

AGS

BC

BCS

CAMP

COAH

COL

CHISCHIH

DGO

GTO

GRO

HGO

JAL

EMO

EMP

MICH

MOR

NAY NL

OAXPUE

QRO QROO

SLP

SIN

SONTABTAM

TLAX

VERNVERS YUC

ZAC

DFN

DFS

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

0 20 40 60 80 100

Usersreportedbein

gveryorsomewhatsatisfied

(AverageJuly-December,2011percentageofall

re

spondents)

Medical Care Internal Processes index 2011

CORRELATION BETWEEN MEDICAL CARE INTERNAL

PROCESSES AND SATISFACTION REPORTED BY USERS1/

(Percentage of satisfied users and Internal Process 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.

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.

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%)


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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

[email protected]

SARA ZETUNE CALDERON

HEAD OF DIVISION OF STRATEGY

IMSS

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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