Performance measurementforhealth …

1 BAC KGROUN DDOCUMENTPerf orm ancemeasurementfor he al thsy stem improvemen t:exp eriences, chal leng esand pro sp ectsPet er C. Smith, Elias Mossialos andIre ne PapanicolasPerformancemeasurementforhe althsystemimprovement:exp eriences,challengesandpr ospectsPe terC. Smith,EliasMossialos andIr enePapanicolas WorldHealthOrganization2008andWorldHealt hOrganization,onbehalfoftheEuropeanObser vatoryonHealthSystemsandPolicies2008 AddressrequestsaboutpublicationsoftheWHO R egionalOfficeforEuropeto:PublicationsWHO Regional OfficeforEuropeScherfigsvej8DK-2100 Copenhagen ,DenmarkAlternatively,completeanonlinere questformfordo cumentation,healthinformation,orforpermi ssio n toqu ot e or translate,ontheRegionalOfficewebsite(h ttp://w ).

2 Allrights theWorld HealthOrganizationwelcomesrequestsforper missiontoreproduceortranslateitspublicat ions,in partorin in thispublicationdonotimplytheexpressionof anyop inionwhatsoeveronthepartoftheWorldHealth Organizationconcerningthelegalstatusofan ycountry,territ or y, cityorar eaorofitsauthorities,orconcerningthedeli mita eremayno t pr oductsdoesnotimplythattheyareendor sedorrecommendedbytheWorldHealthOrganiza tionin pr ef er encetoothersofa ,thenamesofpr opr ietaryproducts ecautionshavebeentakenbytheWorldHealthOr ganizationtoverifytheinformationcontaine din thispu , thepublishedmaterialis beingdistributedwithoutwarrantyofanykind , e materiallieswiththereader.

3 In noeventshalltheWorldHealthOrganizationbe liable fordamagesarisingfr expressedbyauthors,editors,orexpertgroup sdono t necessarilyrepresentthedecisionsorthesta tedpolicyofth e :DELIVERYOFHEALTHCARE - standardsQUALITYIN DICATORS,HEALTHCAREQUALITYASSURANCE,HEAL THCARE- organizationandadministrationEUROPEA uthorsEl ia s Mo ssia lo s, LSEH ealthandEuropeanObservator y onHealthSystemsandPo licies, LondonSchoolofEconomicsan d PoliticalSc ience,UnitedKingd omIr en e Pap an icol as, LSEH ealth,LondonSchoolofEconomicsan dPoliticalSc ience,UnitedKingdomPe te r C. Smith, CentreforHealthEconomics,UniversityofYo rk,UnitedKingdo mCo ntentsPageKeymessagesiExecutivesummaryii Performancemeasurement forhealthsystemimpr ovement:experie nces,challen gesandprospectsPo licyissue1Pu rp oseof performancemeasurement1 Defi ni ng an d measuringperformance2 Methodolo gicalis suesaboutperformancemeasurement6 Usi ng performancemeasurement: keypolicylevers9Su mmaryandco nclusions15 References18 Perfo rmancemeasurementofferspolicy-makersamaj oropp ortunityforsecuringhealthsystemim provement an d accountability.

4 Perfo rmancemeasurementaimstoimprovethequ alityofdecisionsmadebyal l actorswithin th ehealth system. Securingimprovedperformancemeasurementof tenrequirestheactiveleadership ofgovernmen t. Major improvementsaresti ll neededin datacollection, analyticalmethodologies,policydevelopmen tandimplementationofhealthsystemperfor mancemeasurement. Defin itionsof performanceindicatorsshouldbeclear,consi s tentandfi t intoa cl earconceptualframework. Policy-makersshouldpayparticular attentiontothepo liticalandorganizationalcontextwithinwhi c hperfor mancedataarecollectedanddisseminated. Cons iderableprogresshasbeenmadeindevelopingp erforman ceindicatorsforacuteho sp italcare,primary careandpo pulationhealth,bu t formentalhealth,fi nancial protectionan dhealth systemresponsivenessresearchis at a muc hearlierst ag e of development.

5 Thedevelopmentofindividualperformanceind icators requiresconcertedexpertan d politicalat tention, an d these indicatorsshoul d: aimtoprovideinformation thatis relevanttotheneeds ofsp ecific actors; attempttomeasureperformancethatis directlyattributable toanorganizationoractor ; aimtobestatistically sound,easytointerpr etandun ambiguo us ; andbepresentedwithfullacknowledgementofa nydatali mi tations. Thepresentationofperformancemeasurementd ata an d ho w th is influencesitsinterpretation bypatients, providersandpractitionersandthepublicreq uiremore attenti on. Publicreportinghasmanybenefits,butcanlea dtoadverse ou tcomes; mechanismsshould beputinplacetomonitor andcounteracttheseadverseou tcomes.

6 Animport antuseofperfor mance measuremen t isto pr ov ide feedbackto cli nic al practiti oners on theirac ti onsandhowthesecompareto thoseof theirpeers. Perfor mance measurementsy st emssh ouldbemonito redfr equentl y to en sure ali gnment withot herhealth systemmechanis ms an d toidentifyar easfo r improvement. Ex perimentsunderwayto ex amine howperfo rman cemeasurementcanbe usedinconjun ct ion wi thexplici t fi nanci al in centiv estorewardpr ovider per fo rmancear e a pr omising areaforpolicy anda pri or it y forfur th er research. A better ev id encebaseonwhichtounderpinperfo rman cemeasurementpo li cy is needed,an dnewin iti ati vesshould besu bj ecttori gorou sev aluati on.

7 PerformancemeasurementiKeymessagesPerfor mancemeasurementofferspolicy-makersa majoropportunitytosecurehealthsystemimpr ovementandaccount toimprovethequality ofdecisions made by allac torswithin th e healthsystem,in cludingpatients,practitioners,managers,g overn men ts at alllevels,insurersandotherpayers,politic ians, an d majorad vancesin informationtechnologyandin cr easingdemandsforhealthsystemaccountabili tyandpatientchoicehavedrivenrapidadvance sin healthsy st em ,however,arestillin therel ativelyearlystagesofperfor mancemeasurement,andmajorimprovementsar e st ill neededin datacollection,analyticalmethodologies,a n d policydevelopmentandim numberofaspects in cludingpopulationhealth,healthoutcomesfr omtreatment, clinicalqualityandtheappropri ateness ofcare, respon siveness, equityandproducti vity andpr ogress is variedin thedevelopmentofperformancemeasuresandda tacollectiontechni quesforthesedif ferent as progresshasbeenmadein such ar easasacutehospitalcare,primarycareandpop ulatio n health,butin suchareasasmentalhealth,financialprotect ion andhealthsystemresponsiveness.

8 Researchis at a st requirementofanyperformancemeasurementsy st em is tofo rmulatea performanceindicatorsshouldthenfitin to theframework andsatisfya numberofcri teria,suchasfacevalidity,reproducibility , acceptability,feasibility, reliability,sensitivity , policy-makersshouldpaycarefulat tentiontoth e politicalandorganizationalco ntextwithinwhichperformancedataaretobeco llectedan ddissemin technicalquestionsarise whenanalysingandin ter pretin g portan t are:what hascausedtheobservedperfor manceandtowhatpractitioners,organization soragenciessh ouldvariationsin performancebeat tributed?

9 In so meareas,advancedanalyticalmethodsofriska d justment havebeendevelopedtohelpanswerth e someaspectsofhealthcare,patientsafetyis a majorconcern , an d methodsofstatisticalsurveill anceha ofanomalous,th oughnotnecessarilyunsafe,performanceis theoveruseofa parti cular intervention, andtheneedtofin d ou t whetherit meansso mething unsafeforpatientswoul d thenfol lowtheini ti al find ingof anan at tentionshould bepaid tothepresentation ofperformance- measurement dat a andho w patients,providers,practi ti onersan d the pu bl ic int erpret it andar e infl uencedbyit.

10 Fo r ex ample, a particular lycontentiousissueis theuseofcompositemeasuresofperformance,w hi chseektocombi neseveralperformanceind icators int o a si ngl e measure oforganiz at ional orsy aresu perfici al ly attracti ve,astheycanhelpsu mmarizelevel sof attai nment in anaccessibl e fashion,but theycanalsoleadto fau lty inferencesandshould be us edwithcaution .Po li cy-makers canuseperfor mance measurementin anumber of waystopro mote sy stemim pr ovement. It canbe usedinpub lic rep or ting of per fo rman ce, sometimesin theform ofor ganizationalrepor t cards.