EHMA Annual Conference, Athens, Greece

1. EHMA Annual Conference, Athens, Greece 25 – 27 June 2008 Katrien Verleye INCREASING IMPORTANCE OF PERFORMANCE MEASURES IN THE HOSPITAL SECTOR Equity under pressure?

2. Overview • Context • Research questions • Methodology • Results • Discussion

3. CONTEXT REGULATORS AND OTHER ENTITIES Internal members HOSPITAL’S PERFORMANCE Suppliers Consumers and purchasers Kanji & Sá (2003)

4. CONTEXT Ensuring quality as important issue in hospital sector Focus on controlling the financial performance Increased attention for quality improvement cf. lapses in quality Need to control costs without losing quality cf. increasing costs and need in budget

5. CONTEXT • Demand for transparency and accountability • PERFORMANCE MEASUREMENT (PM)… • … translates the hospital’s performance in quantifiable metrics • … informs different stakeholders on the hospital’s performance • … enables stakeholders to follow up, coordinate, control and improve (aspects of) the hospital’s performance

6. RESEARCH QUESTIONS PERFORMANCE MEASUREMENT MODEL development performance measurement interpretation management selection • How is performance defined? • How is performance measured within the hospital sector? • How is performance information used within the hospital sector? • How do hospitals evaluate their performance measurement systems? • Which are the implications of PM on equity in healthcare?

7. METHODOLOGY • Evaluation of PM in hospitals in Belgium • FLEMISH CASE • subjected to the Belgian government Cf. http://www.belgium.be/en/health/index.jsp • subjected to the Flemish government • Cf.http://www.zorg-en-gezondheid.be/HomeEN.aspx?id=1182

8. METHODOLOGY Flemish Region Flemish Communtiy Population: 6,117,440 Total area: 13,522 km² 5 Flemish Provinces • Acute hospitals: • 62 hospitals • 104 campuses • Universitary hospitals: • 4 hospitals • 6 campuses

9. METHODOLOGY • Survey in 13 Flemish hospitals • 2 to 3 hospitals per Flemish province • both universitary and non-universitary • interpretation of each PM step

10. RESULTS * • PERFORMANCE - multidimensional - influenced by stakeholders - context

11. RESULTS * • SELECTION AND DEVELOPMENT OF PIs - measuring all performance aspects: unfeasible and irrelevant - several performance aspects and indicators - motivation • statutory required !!! • supportive networks • self-developed indicators: result of historical factors added value for hospital *

12. RESULTS

13. RESULTS * • BUT • - too many PI’s and unclear definitions • - “not reflecting the performance” • - “difficult to find reliable and valid indicators” • - no participation of employees in the selection *

14. RESULTS * • PERFORMANCE MEASUREMENT • - measurement on the departmental level • - several employees are involved • - mostly supported by ICT

15. RESULTS * • BUT • - lack of motivation • - time consuming • - incorrect and incomplete data • - overlap

16. RESULTS * • ANALYSIS AND INTERPRETATION • - focus on deviating measures • - supported by ICT: basic analysis • - put out the data analysis to supportive network • Government • Navigator • Flemish Hospital Network Leuven

17. RESULTS * • BUT • - feedback government and supportive networks • not satisfactory • - no integration of performance indicators • - lack of standards

18. RESULTS * • USING PERFORMANCE INFORMATION • “what gets measured, gets done” • = ‘the most famous aphorism of performance measurement’ (Behn, 2003) • VERSUS • “to raise questions, not to provide answers” • (Likierman, 1993)

19. RESULTS * • USING PERFORMANCE INFORMATION

20. RESULTS * • BUT • employees are not informed • external use, but limited internal use • cf. ‘information is too general to use’ • cf. ‘PM is not embedded in the decision structure of the organization’ • PM does not achieve its goal

21. DISCUSSION • FOCUS ON USING PERFORMANCE INFORMATION • Comparison among hospitals • Having decisions made by external stakeholders Cf. accreditation • Cf. pay-for-performance • Public disclosure of performance information • Cf. rankings Improving the performance of hospitals (Chandrima, 2005; Hamblin, 2007; Helm, Holladay & Tortella, 2007)

22. DISCUSSION • COMPARISON AMONG HOSPITALS • incomplete and incorrect measures • different ways of measuring indicators • different indicators • different definitions • based on different strategies • different input ! 

23. DISCUSSION • DECISION-MAKING BY EXTERNAL STAKEHOLDERS AND PUBLIC DISCLOSURE • reflecting performance? • cf. tunnel vision(Vakkuri & Melkin, 2006) • is standardization possible? • cf. differences between hospitals • cf. do hospitals have a sector-specific strategy? • getting a good score in stead of improving performance • cf. risk of misrepresentation(Vakkuri & Melkin, 2006) • specializing in a few domains • refusing patients who lower score • risk of ossification (Vakkuri & Melkin, 2006)

24. DISCUSSION • CAUTION IS RECOMMENDED • revising previous steps before use • - reflection • - systematization • adjustment for patients’ characteristics • performance measures are “flags requiring cautious • interpretation in the light of local circumstances” • (Veillard et al., 2005; p. 492) • involvement of different stakeholders

25. Interesting references • Behn, R.D. (2003). Why measure performance? Different purposes require different measures. Public Administration Review, 63( 5), 586-606. • Aidemark, L.-G. (2001). The meaning of balanced scorecards in the health care organisation. Financial Accountability & Management, 17(1), 23-40. • Bauer, K. (2004). KPIs – the metrics that drive performance management. DM Review, 14(9), 63-64. • Becker, B., Formisano, A., & Roger, M.D. (2006). Strategic planning for departmental divisions in an academic health care centre. The American Journal of Medicine, 199(4), 357-365. • Chandrima, B.C. (2005). Accreditation in hospitals. Expressed Healthcare Management. Retrieved May 7, 2008, from http://www.expresshealthcaremgmt.com/20050915/accreditation01.shtml. • Heemskerk, P., & Van Zandwijk, M.C. (2004). Verantwoordingsprocessen in de zorg op basis van de balanced scorecard. Zoetermeer: het Expertise Centrum. • Helm, C., Holladay, C., & Tortorella, F.R. (2002). What’s in a name? Reporting data from public institutions. CMAJ, 22(2), 193-194. • Kanji, G.K., & Sá, P.M. (2003). Sustaining healthcare excellence through performance measurement. Total quality management, 14(3), 269-289.

26. Interesting references • Kollberg, B. Elg, M., Lindmark, J. (2005). Design and implementation of a performance measurement system in Swedish health care services. Quality Management in Health Care, 14(2), 95-111. • Rooney, A.N., & van Ostenberg, P.R. (1999). Licensure, accreditation, and certification: approaches to health services quality. Center for Human Services. Retrieved May 4, 2008, from http://www.qaproject.org/pubs/PDFs/accredmon.pdf • Tarantino, D.P. (2003), Using the balanced scorecard as a performance management tool. The Physician Executive, September-October, 69-72. • Ten Asbroek, A.H.A., Arah, O.A., Geelhoed, J., Custer, T., Delnoij, D.M., & Klazinga, N.S. (2004). Developing a national performance indicator framework for the Dutch health system. International Journal for Quality in Health Care 16(1), 165-171. • Vakkuri, J., & Meklin, P. (2006). Ambiguity in performance measurement: a theoretical approach to organisational uses of performance measurement. Financial Accountability & Management, 22(3), 235-250. • Veillard, J., Champagne, F., Klazinga, N., Kazandjian, V., Arah, O.A., & Guisset, A.I. (2005). A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. InternationalJournal for Quality in Health Care, 17(6),487-496. • Yap, C., Siu, E., Baker, G.R., Brown, A.D., & Lowi-Young, M.P. (2005). A comparison of systemwide and hospital-specific performance measurement tools. Journal of Healthcare Management, 50(4), 251-264.

27. Contact information Vlerick Leuven Gent Management School Reep 1 B-9000 Gent Belgium www.vlerick.com Katrien Verleye Scientific Staff Member + 32 9 210 98 30 katrien.verleye@vlerick.be