Health System Performance Management quality for better or for worse

1. Niek Klazinga, April 27 2010 London LSE/NHS Confederation Health System Performance Managementquality for better or for worse

2. Accountability Strategic decision making Learning/improvement Reasons for international comparisons on performance related to quality of care

3. Table 1.1 Conditions under which performance measurement is possible and problematic Performance measurement possible Performance measurement problematic An organization has products An organization has obligations and is highly value-oriented Products are simple Products are multiple An organization is product-oriented  An organization is process-oriented Autonomous production Co-production: products are generated together with others Products are isolated Products are interwoven Causalities are known Causalities are unknown Quality definable in Quality not definable in performance indicators performance indicators Uniform products Variety of products Environment is stable Environment is dynamic Source: Managing performance in the public sector. De Bruijn H. (2002), p. 13

4. A measure on quality of care does not exist independently validation is dependent on the use/purpose Validation is dependent on the boundaries of the universe it is supposed to signal upon Measures need to be integrated in management/decision making mechanisms of government, financiers, managers, professionals and patients Apart from reliability and validity, relevance and usefullness are important criteria for selecting quality measures As a consequence the users should be involved in the development of the measures Measurement and Management

5. Health Systems (scope , components and boundaries) Performance (objectives on various dimensions such as health results, efficiency and equity – measurement challenges) Management (heterogeneous national governance models, integration of performance indicators in management mechanisms) Health systems performance management

6. Related policies • Health system sustainability • Integrated care • Prevention • Patient Centered Care • Equity • Regulated market • Incentive structures

7. Conceptual Framework for OECD Health Care Quality Indicator (HCQI) Project. (shaded area represents the current focus of the HCQI Project) Source: Arah OA, et al. A conceptual framework for the OECD Health Care Quality Indicators Project. International Journal Quality Health Care. 2006; Sep 18; Suppl.1:5-13. 7

8. Combining various rationalities • Public Health • Medicine • Management sciences • Economics • Societal / individual values

9. avoidable mortality (health system level) standardized mortality rates (hospital level) limitations of death statistics Performance indicators and benchmarking related to mortality data

10. Dutch hospital standardised mortality ratios 2001-3(HSMRs) vs hospital(standardised for age, sex, urgency/readmission, LOS within 50 CCS groups leading to 80% all deaths,excluding small hospitals and those with poor data recording, using year 2000 standard)

11. CONCORD study Eurocare Limitations of cancer registries and limited possibilities for linking with other (administrative) data-bases Performance indicators and benchmarking related to cancer care

18. PATH, OECD, many national projects ………… Limitations (administrative) data-bases Quality of coding practices Lack of (internationally) standardized procedure codes Lack of coding of secondary diagnoses Lack of present at admission coding Lack of linking via UPI’s Limitations Electronic Health Records Performance indicators and benchmarking on care delivered in hospitals

23. Indicators based on administrative databases Adverse event reporting Safety culture Patient Safety Indicators

24. Indicators • Foreign body left in during procedure (PSI 5) • Catheter related bloodstream infections (PSI 7) • Postoperative pulmonary embolism or deep vein thrombosis (PSI 12) • Postoperative sepsis (PSI 13) • Accidental puncture and laceration (PSI 15) • Obstetric trauma -- vaginal delivery with instrument (PSI 18) • Obstetric trauma -- vaginal delivery without instrument (PSI 19) 24

25. Avoidable hospital admissions Lack of comprehensive administrative data-sets Performance indicators in primary care

26. Avoidable hospital admission rates, 2007 Note: Data from Austria, Belgium, Italy, Poland, Switzerland and the United States refer to 2006. Data from the Netherlands refer to 2005. 1. Data does not fully exclude day cases. 2. Data includes transfers from other hospitals and/or other units within the same hospitals, which marginally elevate the rates. 3. Data for CHF includes admissions for additional diagnosis codes, which marginally elevate the rate. Source: OECD Health Care Quality Indicators Database, 2009

27. Service based surveys (CAHPS, Picker, CKZ) Population based surveys (Eurobarometer, WHO, CWF) Lack of standardization Lack of research on validation Lack of research on use Patient experiences

28. Limitations National Information Infrastructures • Mortality Statistics • Registries • Administrative Data-Bases • - secondary diagnoses • - present-at-admission coding • - unique patient identifiers • Electronic Health Records • Household and Patient Surveys • Overall: privacy and data-protection

29. National Information Infrastructures Mortality statistics Registries (cancer) Administrative Databases Electronic Health Records Surveys UPI’s/co-morbidity UPI’s/coding-staging UPI’s, present-at-admission codes, secondary diagnoses Standardized secondary data-use, privacy concerns UPI’s

30. Clinical guidelines Performance indicators Patients’ safety 51% Organizational quality Audit and internal assessment Patients’ views 1.2. Analysis of strategies inter-connection Exploratory Factor Analysis

31. Health System Performance Management • Whole system approach • Sub-optimization • Governance/stewardship • Incentive structure • Interconnection of strategies on performance indicators, guidelines, safety, TQM, patient experiences