Performance Measurement for Health System Improvement: Experiences, Challenges and Prospects (Health Economics, Policy and Management)

In a world where there is increasing demand for the performance of health providers to be measured, there is a need for a more strategic vision of the role that performance measurement can play in securing health system improvement. This volume meets this need by presenting the opportunities and challenges associated with performance measurement in a framework that is clear and easy to understand. It examines the various levels at which health system performance is undertaken, the technical instruments and tools available, and the implications using these may have for those charged with the governance of the health system. Technical material is presented in an accessible way and is illustrated with examples from all over the world. Performance Measurement for Health System Improvement is an authoritative and practical guide for policy makers, regulators, patient groups and researchers. Half-title......Page 3 Title......Page 5 Copyright......Page 6 Contents......Page 7 Foreword......Page 11 Acknowledgements......Page 13 List of contributors......Page 14 Editors......Page 17 Boxes......Page 18 Figures......Page 19 Tables......Page 23 PART I Principles of performance measurement......Page 25 Introduction......Page 27 What is performance measurement for?......Page 29 Defining and measuring performance......Page 32 Statistical tools for analysing and summarizing performance measures......Page 36 Performance measurement in challenging domains......Page 38 Health policy and performance measurement......Page 40 References......Page 44 PART II Dimensions of performance......Page 49 Introduction......Page 51 Does health care contribute to population health?......Page 52 How much does health care contribute to population health?......Page 54 Ischaemic heart disease......Page 57 Perinatal mortality......Page 62 Cancer survival......Page 64 Concept of avoidable mortality......Page 67 Tracer concept......Page 72 The way ahead......Page 74 References......Page 75 Annex 1 Summary measures of population health......Page 83 Uses of PROMs......Page 87 Generic instruments......Page 89 Utility instruments......Page 90 Individualized instruments......Page 91 Evaluating PROMs......Page 92 Evidence to aid choice of instrument......Page 96 Disease-specific versus generic instruments......Page 97 Cognitive barriers......Page 99 Logistic and resource barriers......Page 101 Current and future issues......Page 103 Policy implications......Page 105 References......Page 106 State-of-the-art development of clinical process measures......Page 111 Selecting topics......Page 112 Reviewing clinical evidence......Page 113 Identifying clinical process indicators......Page 116 Data sources......Page 118 Development of measures......Page 120 Creating scoring methods......Page 122 Accreditation......Page 126 Public reporting......Page 127 Payment incentives......Page 129 Best uses of process measurement......Page 130 Recommendations for developing countries......Page 131 Directions for future research......Page 132 References......Page 134 Some preliminaries......Page 138 The basics......Page 140 Empirical studies......Page 144 The basics......Page 147 Empirical studies......Page 148 Is health spending involuntary?......Page 150 Asset sales, dissaving and borrowing......Page 151 Intertemporal considerations......Page 155 Conclusions......Page 157 References......Page 159 Introduction......Page 162 Responsiveness operationalized as a population health concept......Page 163 Spheres of health events......Page 164 Combining health events and user roles – interactions......Page 165 Responsiveness and equity in access......Page 166 Equity considerations for responsiveness survey design......Page 169 Responsiveness questionnaires......Page 170 Feasibility......Page 174 Reliability......Page 176 Validity......Page 179 Calculating the measures......Page 181 Interpreting the measures......Page 184 All countries......Page 185 European countries......Page 186 European countries......Page 188 Ambulatory health services......Page 190 Health system characteristics and responsiveness......Page 192 Common concerns......Page 196 Implementing change......Page 197 Responsiveness measurement and future research......Page 198 Prospects for measuring responsiveness......Page 199 References......Page 200 Introduction......Page 211 Defining equity, access and need......Page 212 What objective of equity do we want to evaluate?......Page 214 How to define access?......Page 216 How to define need?......Page 218 Regression method......Page 223 The ECuity method: concentration index......Page 225 Policy implications and directions for future research......Page 233 References......Page 238 Introduction......Page 246 Conceptual issues......Page 247 Production function – relationship between inputs and outputs......Page 248 Distinguishing productivity and efficiency......Page 251 Defining, measuring and valuing output......Page 254 Defining the quantity of output......Page 255 Defining the quality of output......Page 256 Valuing outputs......Page 257 Defining inputs......Page 258 Labour inputs......Page 259 Health system level......Page 260 3.2 Disease oriented approach......Page 261 Defining comparable organizations......Page 264 Identifying the production frontier......Page 265 Opportunities for meso-level efficiency analysis......Page 267 Conclusion......Page 268 References......Page 269 PART III Analytical methodology for performance measurement......Page 273 Introduction......Page 275 Rationale for risk adjustment......Page 277 Consequences of failing to risk adjust......Page 279 Risk adjustment for different performance measures......Page 282 Outcome versus process measures......Page 283 Measures involving patient preferences......Page 286 Composite measures......Page 288 Conceptualizing risk factors......Page 290 Administrative data......Page 292 Medical records or clinical data......Page 297 Information directly from patients or consumers......Page 299 Statistical considerations......Page 300 Plea for transparency......Page 303 Conclusions......Page 304 References......Page 305 Clinical surveillance: important aspects of the data......Page 310 Throughput of providers and health-care facilities......Page 311 Dimensionality of the data......Page 312 Statistical chart options......Page 313 Example data: cardiac surgery......Page 314 Shewhart charts, scan statistics and MAs......Page 316 EWMAs......Page 318 Sets method......Page 321 Cumulative O – E and CUSUM charts......Page 324 Example data: Harold Shipman......Page 328 Conclusions......Page 330 References......Page 331 Introduction......Page 335 Assumptions underlying performance measurement......Page 337 The vagaries of chance in health-care performance measurement – random error......Page 340 Systematic error in health-care performance measurement......Page 342 Confounding in health-care performance measurement......Page 343 Complexity in health-care performance measurement......Page 344 Provider locus of control......Page 346 Attribution theory and fundamental attribution error......Page 348 Causality and attribution bias in health-care performance measurement......Page 349 Who is at risk from causality and attribution bias?......Page 350 What are the potential effects of causality and attribution bias on health-care quality and equity?......Page 351 Methods to reduce causality and attribution bias in health-care performance measurement......Page 352 Critique from the standpoint of complexity theory......Page 356 Conclusions......Page 357 References......Page 359 Introduction......Page 363 Why use composite indicators to measure performance?......Page 364 Methodological issues and experience of using composite measures in health care......Page 365 Choosing units to assess and organizational objectives to encompass......Page 366 Data availability......Page 369 Type of indicators......Page 371 Collinearity between indicators......Page 372 Combining indicators to create a composite......Page 373 Transformation of individual indicators......Page 374 Weighting......Page 376 Application of decision rules......Page 380 Interpretation and use of composite indicators......Page 382 Conclusions......Page 386 References......Page 388 PART IV Performance measurement in specific domains......Page 393 Defining primary care......Page 395 Importance of measuring performance in primary care......Page 397 Quality of care for individual patients......Page 399 Overview of quality improvement strategies in primary care......Page 400 Underlying conceptual framework......Page 402 Case studies of performance measurement in primary care......Page 407 Case study 1: Quality and Outcomes Framework......Page 408 Case study 2: Veterans Health Administration......Page 412 Case study 3: European Practice Assessment......Page 416 Where should performance measures be used?......Page 418 Is there an optimal way of improving performance?......Page 419 Unintended consequences of performance measurement......Page 420 Future challenges......Page 421 References......Page 423 Growing importance of chronic disease......Page 430 Implications of the growth in chronic disease......Page 434 Assessing performance: different dimensions......Page 436 The health system perspective......Page 439 Towards high-performing health systems......Page 443 References......Page 445 Introduction......Page 450 Performance measurement in mental health......Page 452 Challenges in measuring health outcomes......Page 455 Australia......Page 456 England......Page 458 Netherlands......Page 459 Readmission rates......Page 460 Suicide......Page 462 Physical health problems......Page 463 Is there any evidence that outcome measurement leads to service improvement?......Page 464 Process measures......Page 465 Service-user experiences......Page 466 Use of guidelines......Page 468 Inequalities in access and utilization......Page 470 Productivity measurement......Page 473 Risk adjustment......Page 476 Expanding the dimensions of performance assessment......Page 477 Performance data and IT......Page 479 Conclusions......Page 481 References......Page 485 Introduction......Page 496 Origin of the RAI in the United States......Page 497 Reliability and validity of the MDS......Page 499 Policy applications of the RAI......Page 500 Casemix reimbursement......Page 501 Creating quality indicators to monitor provider performance......Page 502 Nursing Home Compare in the United States......Page 505 Benchmarking initiatives involving interRAI data in Canada......Page 507 RAI benchmarking project in long-term care......Page 511 Benchmarking in intra-facility management......Page 514 Nursing home performance measurement in Swiss cantons: Q-Sys approach......Page 515 Summary and implications......Page 517 Policy challenges......Page 518 Research needs......Page 520 Conclusions......Page 521 References......Page 522 PART V Health policy and performance measurement......Page 531 Introduction......Page 533 Targets in the English health system......Page 534 An example: 2004 PSAs for the Department of Health......Page 536 Discussion......Page 542 Who should choose the targets?......Page 543 What targets should be chosen?......Page 546 When should outcomes be used as a basis for targets?......Page 547 How should targets be measured and set?......Page 548 How should cross-departmental targets be handled?......Page 551 How should attainment be scrutinized?......Page 552 How should departmental objectives be transmitted to local organizations?......Page 553 Conclusions......Page 554 References......Page 558 Introduction......Page 561 Public reporting: effect on selection pathway......Page 562 By health plans or individual providers......Page 563 Public reporting: effect on clinical outcomes......Page 564 Public reporting: potential for unintended consequences......Page 565 Evidence about public reporting......Page 566 HEDIS......Page 567 Hospital Compare......Page 568 Unit of Patient Evaluation......Page 569 Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG)......Page 570 Netherlands......Page 571 References......Page 572 Infrastructure of health information network......Page 576 Penetration of health IT......Page 582 Health-care effectiveness......Page 585 Patient safety......Page 589 Health-care equality......Page 592 Data quality......Page 593 Patient privacy......Page 596 Key policy issues......Page 597 The future......Page 598 Conclusions......Page 599 Challenge 2: ensure data exchangeability......Page 600 References......Page 601 Introduction......Page 606 Theoretical framework......Page 607 Target entity......Page 608 Types of incentive......Page 609 Extrinsic and intrinsic incentives......Page 611 Behaviour targeted by the incentive......Page 612 Certainty of incentive application......Page 614 Base of comparison: relative versus absolute performance measures......Page 615 Health plan to provider organization incentives......Page 616 Physician organization-based (group-level) selective incentive studies......Page 618 Hospital-based selective incentive studies......Page 619 Individual physician-based selective incentive studies......Page 621 Unintended consequences of performance incentives......Page 622 Nature of the incentive (reward versus penalty)......Page 623 Type of incentive......Page 624 Nature of behaviour subject to incentive......Page 625 Certainty, frequency and duration of incentive......Page 626 Implications for research and policy in performance incentive design......Page 627 References......Page 629 Quality assurance, quality improvement and performance measurement......Page 637 Education......Page 639 Audit, profiling and feedback......Page 642 Accreditation and recertification......Page 647 Publicly released performance data......Page 649 Providers' response to report cards......Page 650 Pay for performance......Page 652 Quality measurement to encourage professional participation......Page 654 Policy questions and future challenges for performance measurement and professionals......Page 655 How can physicians be encouraged to utilize performance measurement and engage more actively in quality improvement?......Page 656 How to create consortia to better map performance and provide consistent signals?......Page 657 When financial incentives are tied to publicly reported data, what are the most appropriate targets (attainment or improvement) and what are the levers that will prompt change most effectively (the magnitude of the incentive or professional ethos)?......Page 658 References......Page 659 Introduction......Page 665 Increased interest in international health system comparisons......Page 668 Scope of international health system comparisons......Page 669 Methodological issues in conducting international health system comparisons: lessons from the OECD experience......Page 676 Specifying indicators using internationally standardized definitions......Page 679 Controlling for differences in population structures across countries......Page 680 Adjusting for differences in information systems’ ability to track individual patients......Page 681 Controlling variability of data sources......Page 682 Identifying nationally representative data......Page 685 Turning international health system comparisons into health system performance management......Page 686 Translating performance information for policy-makers......Page 688 Benchmarking health system performance......Page 689 Conclusions......Page 691 References......Page 692 PART VI Conclusions......Page 697 6.1 Conclusions......Page 699 Conceptual framework......Page 700 Integrate with IT and routine data collection......Page 701 Design for international comparability......Page 702 Choosing performance measures......Page 703 Statistical issues......Page 708 Incentives and performance information......Page 712 Politics of performance measurement......Page 721 Stewardship perspective on performance measurement......Page 723 References......Page 728 Index......Page 731 P I. Principles Of Performance Measurement: 1. Introduction Peter C. Smith, Elias Mossialos, Sheila Leatherman And Irene Papanicolas; P. Ii. Dimensions Of Performance: 2. Population Health Ellen Nolte, Chris Bain And Martin Mckee; 3. Patient Reported Outcome Measures And Performance Measurement Ray Fitzpatrick; 4. Measuring Clinical Quality And Appropriateness Elizabeth A. Mcglynn; 5. Measuring Financial Protection In Health Adam Wagstaff; 6. Health Systems Responsiveness: A Measure Of The Acceptability Of Health-care Processes And Systems From The User's Perspective Nicole Valentine, Amit Prasad, Nigel Rice, Sivana Robone And Somnath Chatterji; 7. Measuring Equity Of Access To Health Care Sara Allin, Cristina Hernández-quevedo And Cristina Masseria; 8. Health System Productivity And Efficiency Andrew Street And Unto Häkkinen; P Iii. Analytical Methodology For Performance Measurement: 9. Risk Adjustment For Performance Measurement Lisa I. Iezzoni; 10.^ Clinical Surveillance And Patient Safety Olivia Grigg And David Spiegelhalter; 11. Attribution And Causality In Health-care Performance Measurement Darcey D. Terris And David C. Aron; 12. Using Composite Indicators To Measure Performance In Health Care Maria Goddard And Rowena Jacobs; Part Iv. Performance Management In Specific Domains: 13. Performance Measurement In Primary Care Helen Lester And Martin Roland; 14. Chronic Care Martin Mckee And Ellen Nolte; 15. Performance Measurement In Mental Health Services Rowena Jacobs And David Mcdaid; 16. Long-term Care Quality Monitoring Using The Interai Common Clinical Assessment Language Vincent Mor, Harriet Finne-soveri, John Hirdes, Ruedi Gilgen And Jean-noel Dupasquier; Part V. Health Policy And Performance Management: 17. Targets And Performance Measurement Peter C. Smith And Reinhard Busse; 18. Public Performance Reporting On Quality Information Paul G. Shekelle; 19.^ Developing Information Technology Capacity For Performance Management Thomas D. Sequist And David W. Bates; 20. Incentives For Health-care Performance Improvement Douglas A. Conrad; 21. Performance Information And Professional Improvement Arnold M. Epstein; 22. International Health System Comparisons: From Measurement Challenge To Management Tool Jeremy Veillard, Sandra Garcia-armesto, Sowmya Kadandale And Niek Klazinga; P. Vi. Conclusions: 23. Conclusions Peter C. Smith, Elias Mossialos, Sheila Leatherman And Irene Papanicolas; Index. Population Health / Ellen Nolte, Chris Bain, Martin Mckee -- Patient-reported Outcome Measures And Performance Measurement / Ray Fitzpatrick -- Measuring Clinical Quality And Appropriateness / Elizabeth A. Mcglynn -- Measuring Financial Protection In Health / Adam Wagstaff -- Health Systems Of Responsiveness : A Measure Of The Acceptability Of Health-care Processes And Systems From The User's Perspective / Nicole Valentine ... [et Al.] -- Measuring Equity Of Access To Health Care / Sara Allin, Cristina Hernández-quevedo, Cristina Masseria -- Health System Productivity And Efficiency / Andrew Street, Unto Häkkinen -- Risk Adjustment For Performance Measurement / Lisa I. Iezzoni -- Clinical Surveillance And Patient Safety / Olivia Grigg, David Spiegelhalter -- Attribution And Causality In Health-care Performance Measurement / Darcey D. Terris, David C. Aron -- Using Composite Indicators To Measure Performance In Health Care / Maria Goddard, Rowena Jacobs. Performance Measurement In Primary Care / Helen Lester, Martin Roland -- Chronic Care / Martin Mckee, Ellen Nolte -- Performance Measurement In Mental Health Services / Rowena Jacobs, David Mcdaid -- Long-term Care Quality Monitoring Using The Interai Common Clinical Assessment Language / Vincent Mor ... [et Al.] -- Targets And Performance Measurement / Peter C. Smith, Reinhard Busse -- Public Performance Reporting On Quality Information / Paul G. Shekelle -- Developing Information Technology Capacity For Performance Measurement / Thomas D. Sequist, David W. Bates -- Incentives For Health-care Performance Improvement / Douglas A. Conrad -- Performance Measurement And Professional Improvement / Arnold M. Epstein -- International Health System Comparisons : From Measurement Challenge To Management Tool / Jeremy Veillard ... [et Al.]. Edited By Peter C. Smith ... [et Al.]. Includes Bibliographical References And Index.