The Hong Kong Private Hospitals Association adopted the idea of Benchmarking as a way to improve knowledge and practices among the member hospitals. Funding from the Professional Services Development Assistance Scheme of the Government of the Hong Kong Special Administrative for this project is awarded for this project.

Seven areas of hospital services for this round of benchmarking were identified, namely, General Management Arrangements, Nursing Services, Laboratory Services, Resuscitation, Sterile Supplies and Storage, Hospital Information and Health Records Management, and Catering Services. With input and endorsement from Trent of National Health Service of England, benchmarking questions based on their survey document were developed for these areas.

Current management studies agree that Knowledge is the most important assets of an organization. The book value of tangible items like renovation, CT Scanner, or drugs is only a small portion of our capitals. Knowledge is intangible and tacit. It is created and kept in staff's mind. It requires much effort to extract, express, and exhibit them for the good of all. Hospital care is a labour and professional intensive service. With our average staff cost close to 70% of the total expenses, hospitals should be the first batch of organizations doing Knowledge Sharing and Knowledge Management.

The purpose of the Benchmarking Study is to provide a reference point for and insight into the processes and practices among the 12 private hospitals. It should be used as an educational learning tool and not as a "recipe" or step-by-step procedure to be copied or duplicated in any way. A Good Practices Summary is written based on interview with some hospitals with good practices. The first step of Knowledge Sharing among private hospitals is achieved through the Benchmarking Study.

The Benchmarking Study follows the four-phase benchmarking methodology of the Asian Benchmarking Clearinghouse of the Hong Kong Productivity Council which licensed from American Productivity & Quality Centre: planning, collecting, analysing/reporting and adapting. It is a powerful tool for identifying the best and most innovative practices and for facilitating the actual transfer of these practices.

Key Finding 1: All private hospitals are committed to quality and reliable services to improve patients' quality of life, by providing patient centred holistic care and evidence-based practice.

Key Finding 2: Private hospitals consider providing a safe environment and good customer service a high priority in managing a hospital.

Key Finding 3: Private hospitals consider staff training and development, performance review and quality assurance programmes, to be important to ensure quality care is delivered.

Key Finding 4: Professional leadership is significant in changing/improving nursing practice based on research.

Key Finding 5: Staff cost makes up a significant portion of a hospital's total expenditure.

Key Finding 6: There is a tendency to use electronic systems to store / retrieve patients' medical records in/from the laboratory.

Key Finding 7: On the subject of the average turn-around time to report test results urgently, the best practices among the benchmarking group are 10 minutes for Haemoglobin and Urea and 25 minutes for Blood Transfusion.

Key Finding 8: On the subject of the response time of the resuscitation team, the best practice among the benchmarking group is 1 to 2 minutes.

Section V: Sterile Supplies and Storage
Key Finding 9: Automatic identification technology is another alternative for hospital supplies labeling usage.

Section VI: Hospital Information and Health Records Management

Key Finding 10: Most of the private hospitals use conventional door locks and keys to limit access to patients' medical records and most of them require written authorisation to access and release these medical records.

Key Finding 11: Almost all private hospitals have an audit programme to ensure doctors complete discharge summaries and sign all pertinent documents.

Key Finding 12: Almost all private hospitals have full compliance in patients' identity / passport numbers being recorded on relevant documents, and a high percentage of compliance in recording of drug allergies and discharge summaries.

Section VII: Catering Services

Key Finding 13: The Catering Service is seen as an important support service of all hospitals and the majority conduct customer service surveys at least annually.

This section collects the practices performed by the private hospitals in the benchmarking study. The main purpose of this summary is to allow the benchmarking participants to learn from the practices of other private hospitals.

After comparing the results of the benchmarking questionnaires, the best performers in specific areas are invited to share their practices. Overall, there are twenty-two practices being shared from the private hospitals. These practices are divided into seven areas, namely, Staff Assessment, Complaint Handling, Needle Stick Indices, Laboratory Turn-around Time, Resuscitation Trolleys, Resuscitation Support Teams and Customer Surveys on Catering.

Based on the Code of Conduct of the benchmarking study, the hospital's identity will not be shown on the report so that the reader cannot identify the owner of individual practices. As a result, each individual practice in this section is named as Hospital A to V. Each practice in this section comes from one individual private hospital. For example, there are three practices under Section Three A: Staff Assessment. It means that three private hospitals have shared their own practices in this specific section.

Hospital A
Introduction
Employees are the organization's most important asset in determining its success or failure. As the mission of the Hospital is to provide excellent health services to patients, its management should be aware that development of human resources is one of the elements in contributing to the fulfillment of this mission. Staff performance review is one of the methods of assessing the accountability and
dedication of the staff towards their jobs. Among different assessment criteria, five of the most important standards are "Basic Job Responsibility" , "Department / Team Target", "Specific Objectives", "Training & Development" and "Punctuality and Attendance" ranked in descending order of importance.

Basic Job Responsibility
A set of job descriptions and specifications have been written by all departments /wards for their staff. All appointed staff should be very clear of their job responsibilities and the expectations of the Hospital towards them. During staff performance review, the Hospital believes that the most basic and important criterion is to evaluate whether the staff can perform the present job responsibilities to meet the Hospital's expectations.

Department / Team Target
Apart from meeting the "Basic Job Responsibility", staff are also expected to meet the department / team target. Since they are working in the Hospital as part of a team, co-operation among staff to achieve excellent results is strongly required. Every department has its own departmental manual as well as a procedural manual for specific job functions. Through periodic departmental meetings, staff clearly understand their responsibilities and common targets towards success.

Specific Objectives
With the fulfillment of the above two criteria, specific objectives are another key factor for evaluation during performance review. The Hospital has to set some specific objectives for staff. Also there is a competency checklist and a "Supervision and Reflective Practice" form for the supervisor to evaluate their subordinates from time to time. Senior staff are required to fill in the "Personal Development Plan Reflection Section". By completing this form, they can review the past year's performance and plan for the next year. Moreover, the Hospital also promotes audit programmes for continuous quality improvement.

Training and Development
The Hospital promotes continuing and life-long learning for all staff. This is one of the major criteria in performance review. Every staff member is encouraged to attend internal and external courses in order to enhance their knowledge and skills in carrying out their jobs more effectively and efficiently. There are mandatory lectures, such as, staff induction programmes, ICAC, fire safety, continuous quality improvement / customer services courses, etc., which all staff are required to attend.

Staff are also encouraged to propose different training topics to the Education and Training Unit (including job-related or non job-related courses). The Hospital sponsors staff to attend courses during working hours. After their attendance, staff are required to evaluate the lecture in order to suggest further improvement. Twice a year, every employee receives a training record from the Education and Training Unit through the department head. For external lectures / seminars / conferences, staff can apply for training sponsorship and they are encouraged to share the knowledge acquired with their colleagues, after completion of the courses.

Punctuality and Attendance
The last but not least important criterion during staff performance review is "Punctuality and Attendance". The Hospital believes that being punctual for work with good attendance is important to achieve good results. The supervisors keep departmental records and monitor the punctuality of their staff. For staff attendance, sick leave records for all staff are kept in each department as well as in the Human Resources Department.

Conclusion
Staff performance review provides a focus on the future development of staff based on the achievement of results and overall performance. The review can facilitate constructive communication between supervisors and their subordinates in achieving hospital, departmental and personal goals.

Hospital B
The hospital has a continuous education committee which is responsible for arranging essential training and compulsory training for different levels of staff. The hospital adopts a continuous development point system that requests staff to have a minimal training level before their annual appraisal interview. Staff are also requested at the beginning of each year to set up an individual training plan agreeable with one's manager to complement the overall hospital services.

Hospital C
1. The hospital has a Mentored Orientation Programme of a defined period, usually from 1 to 3 months, depending on the responsibility and complexity of the job, and all staff are required to participate.
2. New staff are evaluated in the middle and at the end of the Orientation Programme. During this evaluation, essential information, general information and core skills for the specific post are recorded to guide the mentor to coach and supervise.
3. Staff are then assessed for the suitability of the post at the end of the Probation Period following this close monitoring during the Orientation Programme.
4. Training needs and expected performance targets are defined for the Individual Performance Review (IPR) before the probation period ends.
5. Department Heads / Supervisors are responsible for monitoring and supporting staff for the remaining period before the next IPR is due, usually on the anniversary of the commencement date.
6. There is sponsorship defined in the Hospital's Training Policy to encourage staff's continual training to support their careers and the Hospital's service needs.
7. At the annual appraisal (IPR), staff performance targets and training needs are assessed and new targets for the following year / defined period are incorporated to form a continual staff development programme.
8. The Hospital has an established record of internal / external training courses tabulated for different professional grades of staff. There are pre-defined minimal learning credit points, e.g. Continuing Nursing Education, CME, Pharmacist and Accountant. This ensures that staff are complying with the mandatory educational needs required by their professional bodies. These learning credit points and the contents of courses attended are taken into consideration in the staff's annual appraisal or for promotion or salary increments.

Hospital D
With Customer Service being regarded as one of the most critical priorities in managing the hospital, prompt response to customers' requests is essential. With management commitment, training regarding customer needs and complaint handling is a mandatory topic each year, and it is well emphasised in the staff orientation programme. The Hospital is committed to prompt and effective response to handling of complaints, to avoid escalation of complaints. Teamwork and good inter-communication are also essential elements of success in handling complaints
within the shortest time. All complaints are immediately followed up by the Customer Service Manager or Matron, either, via the telephone, going to the wards to meet the complainants, or through mail and email.

Hospital E
There is a 24 hour staff member in charge overall to deal with complaints regarding the hospital. He/she is empowered to handle and settle complaints as soon as possible. In case the complaints involve medical or legal implications advice is sought from hospital management or the Medical Superintendent. The hospital has a service pledge to give feedback within 7 working days.

Hospital F
It is the intent and the concern of the Hospital to handle and resolve each complaint as soon as possible, whether it is lodged directly by the complainant to the Hospital or channeled through other parties, such as the Department of Health, the media, etc. Therefore, the objective of the complaint handling policy is to ensure that complaints are handled and resolved efficiently, with corrective / preventive actions implemented appropriately.

The Chief Administration Officer and the Duty Supervisor are designated "Complaint Handling Officers" to deal with complaints which cannot be resolved by staff on the spot. As soon as a complaint is brought to their attention, they will respond immediately by approaching the complainant either personally or via telephone. Such response normally takes place within 4 hours of the complaint being brought to their attention. The objective is to acknowledge receipt of the complaint, taking the opportunity to get more information concerning the complaint and assuring complainants that they will be informed of the outcome of investigations. Complaints will then be promptly and properly investigated, analysed, and recorded. Feedback to the complainants and staff concerned, and where necessary to the hospital management, will normally be provided within a week, depending on the complexity of the complaint.

It has widely been believed that complaints can serve as useful indicators of the quality of service and client satisfaction. Complaints are also opportunities for service improvement. Therefore, a complaint digest is compiled monthly and this is reviewed at the hospital CQI Committee.

Hospital G
There is a Complaint Handling procedure for all staff to follow as the hospital has engaged a full time Customer Service Assistant to obtain details from complainants as an initial contact. The full time Customer Service Assistant will try to establish a rapport with the complainant in a sympathetic manner.

As to resolution of substantiated complaints, these will be immediately reported to the Chief Hospital Manager via the Customer Service Officer along with investigation results and root cause analysis. The complainant is offered explanations and options for settling the dispute. For normal working practice, 3 days would be the average working time to draw down results and to report to the complainant and this target is attained in most circumstances.

III: Needle Stick Indices

Hospital H
The hospital emphasises correct training in concept and practice in relevant skills where needle stick injuries may occur; this is as required for different levels of hospital staff. All clinical departments including the laboratory carry out risk assessment to reduce the possibility of needle stick injury and modification of practices are made accordingly where necessary. . Hospital management is committed
to supporting relevant resources as necessary.

Hospital I
The hospital finds the following reasons for zero needle-stick injury:
1. Appropriate training in phlebotomy which is conducted at other institutions (e.g. OUHK & SPACE).
2. Staff experienced in phlebotomy.
3. Usage of Vacuation phlebotomy techniques to minimise the injury.
4. Avoidance of re-capping of needles after use. If needed, the one-hand re-cap method is used.
5. A sharps box is provided on site in order to safely dispose of used needles as soon as possible.

Hospital J
The hospital uses the Venojet system which can eliminate needle stick injuries and enhance the safety of blood drawing procedures.

Hospital K
Needle stick injury is one of the most common occupational risks among front line hospital staff. To achieve a low or even zero needle stick injury index, standard operating procedures and training are two important components. Standard operating procedures are practiced daily referring to Universal Precautions, which include:
1. Engineering and work practice controls
2. Personal protectiveequipment
3. Labels and signs.

Review of standard procedures and exposure incidents are carried out on a regular basis, either in the Clinical Laboratory or in the Occupational Safety and Health Committee meetings.

Tailor made training is arranged to cover all employees where it can be "reasonably anticipated" as a result of performing their job duties that they may have contact with sharps, e.g. all laboratory staff and ward service attendants. Training is given upon commencement of employment or assignment to tasks involving sharps handling. Annual retraining is given to ensure that everyone is aware of the risks and what to do about them.

The Laboratory staff members in the Hospital need to draw blood from patients for collection of blood samples. Thus their work involves risk through direct needle handling. Mishandling or mislabeled sharps waste including needles are major hazards that can result in serious injuries to ward service attendants when they handle them. Therefore, all needles are discarded in designated sharp containers and with the containers properly labeled.

To achieve a zero Needle Stick Index, all laboratory staff members and ward service attendants play an important role.

Hospital L
A low Needle Stick Index in the hospital is the result of OSH promotion and good equipment used.

1. OSH promotion
a. Posters reminding staff to wear PPE and practicing Universal Precautions increases the awareness of staff towards biohazards including needle stick injuries.
b. Staff have good knowledge of the seriousness of blood-borne viruses including Hepatitis Virus and HIV. This makes them very cautious when performing jobs involving needles.

2. Good equipment
The use of sharp boxes is a major factor contributing to zero needle stick injuries in the laboratory. The sharp box changes the behaviour of recapping needles and confines the needles in an unbreakable and unpenetratable plastic box.

All hospitals use sharp boxes. The way staff use them will make a difference to whether injuries do or do not occur. Emphasis should be placed on the importance of proper use of sharp boxes. First, sharp boxes must be puncture resistant, leakproof and labeled - the quality of the hospital's sharp boxes are up to standard.

Secondly, they should be readily available - the hospital has sharp boxes placed around the laboratory. Sharp boxes (small size) are placed in blood collection trays which can be carried to the wards and used together with the blood drawing step conveniently. Thirdly, sharp boxes must not be overloaded (staff should check the sharp box frequently and change it when the content of the box is up to the warning line) and should be maintained upright to hold the contents.

The Fishing Technique (the proper name is One-handed Recapping Technique) is not always recommended but is a correct and useful technique to be employed when immediate disposal is not possible. Staff, including nurses should be aware of this technique as in certain situations recapping is necessary (i.e. when drawing up an injection solution which will then be taken elsewhere for injection).

IV: Laboratory Turn-around Time (TAT)

Hospital M
The Hospital achieves a short TAT because it provides a holistic customer focused service. The technician will take the blood sample and process the specimen as soon as possible. The equipment used for Urea and Haemoglobin testing are Dimension RxL and Cell-dyn respectively. To ensure accuracy levels, the laboratory has a QC programme within the Lab. Information System which records the CV for both tests at 3.8% and 0.95% and SD at 0.189 and 0.131 respectively.

Hospital N
Most of the equipment in the laboratory has been replaced by electronic automatic processing systems during the last couple of years. An automatic self-processing test is performed before each day's operations and counter checks are made at regular intervals. The laboratory also participates in different quality assurance programmes available in Hong Kong to keep a close monitor on performance. In the event that there is any query about the results produced, it is routine to have another counter check it to clarify the result.

Hospital O
Most of the lab. tests are performed by automatic machines. The time taken for the machine to analyse urea and hemoglobin can be just a couple of minutes. The TAT (i.e. Turn-around time or the time interval between specimen receipt and results reported and available on the floor) are determined by three separate phases
1. the pre-analytical phase (this includes activities like registration, centrifugation, separation of serum)
2. the analytical phase as mentioned above can be a couple of minutes and the length will be affected by the workload and complexity of the test.
3. the post-analytical phase

The post-analytical phase can range from a couple of minutes to a few hours. (Experience of laboratories indicates the test may be completed but there is a delay whilst waiting for verification and endorsement).

If the answers of Q31 (routine order) and Q32 (urgent order) are compared, it is noted that there is a tremendous shortening of the average TAT. To determine why this is so, questions that need to be asked are: Can it be the attitude change of staff towards urgent tests? Can it be the department's policy which governs the workflow of urgent tests which is different from those for routine tests? What is the determination factor of the TAT? What phases (see above) is the factor associated with?

Customers expect quality service which includes a short TAT. Short TAT can contribute to short hospital stays and shorten the period of physiological stress for patients whilst they are waiting for laboratory reports. If a Customer Service Standard were to be drafted, an important element would be the TAT of service or response time. It can be a parameter to be compared among competitors.

One of the major factors contributing to the short TAT of Hb and Urea for the Hospital can be understood as follows: these tests are mainly requested by Dialysis Units (DU). DU patients will be checked for Hb and urea before and after dialysis. Usually these tests and reports are completed as soon as possible even if no "Stat or Urgent" is marked on the request form. The Laboratory staff have acknowledged that completing all DU tests as being urgent. This helps DU staff to better manage
the patients.

V: Resuscitation and Resuscitation Trolley

Hospital P
1. The Hospital's resuscitation trolleys are located within easy access in various clinical areas.
2. The wards practice is to nurse critically ill patients near the nurse's station.
3. Staff attend a CPR drill once or twice a year, depending on the criticality of ward that they work in or the type of patients they nurse.
4. The average time taken for the resuscitation trolley to be delivered to a patient's bedside (i.e. wards) has been derived from data collected in routine CPR drills and Post CPR Case Evaluation/ Review, and is reported to be under 60 seconds.

Hospital Q
Despite the relatively small size of all clinical departments in the Hospital, there is at least one resuscitation trolley located in each patient area to facilitate fast access at any corner of the department. Each department with patients has checked the time to access the resuscitation equipment and remedial actions have been taken where necessary to ensure speedy delivery of trolleys.

Hospital R
1. A resuscitation trolley is available in each Nursing Unit of the hospital.
2. There is a Code Blue Call button in each of the patients' rooms. Once the button is pressed to alert resuscitation, a nurse will move the resuscitation trolley from the nursing station to the site immediately.
3. The hospital conducts CPR Drills and audit for staff periodically.

VI: Resuscitation Support Team

Hospital S
1. The hospital carries out evaluation and gives recommendations for improvement after every CPR Drill and audit exercise.
2. When there is a Code Blue Call, the alarm will be set off in all units simultaneously. A nurse from each of the other units and the on-call doctor will immediately attend the scene.

Hospital T
The Hospital has a Group Paging System to alert the whole CPR team, once the cardiac or respiratory arrest is confirmed. This group paging would be activated and the whole team including a Doctor and a nursing team of 3 nurses would attend at the site. The response time of the resuscitation support team from 1 to 2 minutes was drawn from CPR drills and some cases of Post CPR Evaluation.

VII: Customer Survey on Catering

Hospital U
The Hospital conducts the customer survey by interview.

Hospital V
The Hospital Administration Department is responsible for monitoring the contracted out catering services. The monitoring system includes:
i) Annual questionnaires to all staff
ii) Twice weekly visits to the kitchen and canteen for environmental and food quality assessment
iii) Monthly audits on the site including surprise food audit on patients'orders and collecting clients' feedback in person by the Administrative Officer and Catering Manager in two wards at random.
The Long Stay Patients (LOS > 3 days) are approached by ward staff to complete the Service Quality Survey (SQS).