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From information to improvement: evidence from UK & US. 27 April 2010 Gwyn Bevan. Information  improvement. Three pathways & evidence from US Change Selection Reputation Evidence from UK Questions. Selection & Change. Aware of differences. Results. Knowledge about

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Information improvement
Information  improvement

  • Three pathways & evidence from US

    • Change

    • Selection

    • Reputation

  • Evidence from UK

  • Questions


Selection change
Selection& Change

Aware of

differences

Results

Knowledge about

process & results

Knowledge about

performance

Management &

Professionals

Implement change

Consumers

able to choose

Motivation

Adapted from Berwick et al. 2003


Evidence from two systematic reviews
Evidence from two systematic reviews

  • Limited evidence

    • Industry of performance assessment

    • Rigorous evalution

      • Cardiac Surgery Reporting System (CSRS)

      • 6 other US systems

  • Change

    • Weak evidence

  • Selection

    • No evidence providers respond to threat of patients using information as consumers

    • Ineffective in US  likely to work in UK?

Sources: Marshall et al (2000) & Fung et al (2008)


Csrs 2001 cabg outliers good poor outcomes
CSRS (2001): CABG outliers good & poor outcomes

RAMR

Rates

Source: http://www.health.state.ny.us/statistics/diseases/cardiovascular/


The clinton s selection pathway 2001 csrs data available
The Clinton’s selection pathway (2001 CSRS data available)

  • sudden onset of chest pains & shortness of breath (September 2004)

    • small hospital near home

    • cardiologists @ Westchester Medical Center

    • quadruple bypass @ Columbia-Presbyterian

Source:http://www.nytimes.com/2004/09/06/health/06hosp.html?scp=1&sq=Clinton%20Surgery%20Puts%20Attention%20on%20Death%20Rate&st=cse


Csrs 2001 cabg outliers good poor outcomes1
CSRS (2001): CABG outliers good & poor outcomes

RAMR

Rates

Westchester Medical Center

Columbia Presbyterian

Source: http://www.health.state.ny.us/statistics/diseases/cardiovascular/


Csrs pathways
CSRS: pathways

  • Change

    • mediocre / below-average performance: failed to use rich performance data

  • Selection

    • outliers with good / poor performance: no changes in market share

  • Reputation

    • outliers with poor performance: ‘naming & shaming’  galvanised to improve

Source: Chassin (2002)


3 rd pathway reputation

Characteristics

ranking

published: widely disseminated

easily understood: performance good or poor?

future report: performance improved?

Paradox

information not used by patients to switch from poor to good hospitals

managers of poor hospitals respond to repair perceived damage to public reputation not market share

3rd Pathway: Reputation

Sources: Hibbard et al. (2003, 2005)


Controlled experiment in wisconsin
Controlled experiment in Wisconsin

  • Summary indices adverse events

    • Deaths & complications)

    • General: surgery / nonsurgery

    • Specific: cardiac, maternity, & hip/knee

  • System characteristics

    • Ranking, easily understood, followed up

Source: Hibbard et al. (2003, 2005)


Wisconsin pathways
Wisconsin: pathways

  • Change:Private report

    • little effort to improve quality

  • Selection: Public report

    • no anticipated changes in market share

    • no actual changes in market share

  • Reputation: Public report

    • significantly greater efforts to improve quality because of concerns over reputational damage

Source: Hibbard et al. (2003, 2005)


Information improvement1
Information  improvement

  • Three pathways & evidence from the US

  • Evidence from UK

    • Changing policy mix in England

    • Natural experiment

    • Evidence

  • Questions


Changing policy mix in england
Changing policy mix in England

  • 1997-99: Selection  Change

    • ‘internal market’  ‘third way’

  • 2000-02: Reputation

    • star ratings (2001 – 05)

  • 2002 - : Reputation & Selection

    • Reputation: star ratings  healthcheck (2006)

    • Selection: FTs & ISTCs, PbR, patient choice, & World Class Commissioning



England selection change 1997 manifesto pledge waiting lists
England: Selection  Change1997 manifesto pledge  waiting lists

Numbers waiting elective admissions (England) (‘000s)


Star rating reputation naming shaming zero stars

‘devastating …hit right down to the workforce – whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

Star rating: Reputation ‘naming & shaming’ zero stars

2001:the dirty dozen

Source: Mannion et al (2005)


England change reputation
England: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change  Reputation

Numbers waiting elective admissions (England) (‘000s)

Star ratings

published


Funding of uk s natural experiment
Funding of UK’s natural experiment whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’


Natural experiment change reputation
Natural experiment: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change & Reputation

No/‘000 waiting > 6 months for elective hospital admission


Natural experiment change reputation1
Natural experiment: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change & Reputation

% waiting list < 13 weeks for hospital admission (March 2008)

Source: Connolly et al (2010) Funding and Performance of Healthcare Systems in the Four Countries of the UK before and after Devolution. The Nuffield Trust.


Natural experiment change reputation2
Natural experiment: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change & Reputation

No/‘000 waiting > 3 months GP  1st outpatient appointment


England change reputation1
England: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change  Reputation

% Ambulance response times to life-threatening emergencies < 8 minutes (Target 75%)

Reputation

Change

Source: Bevan & Hamblin (2009)


Natural experiment change reputation3
Natural experiment: whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Change & Reputation

% Ambulance response times to life-threatening emergencies < 8 minutes

Star ratings published

Target 

Source: Bevan & Hamblin (2009)


Barber 2007 instruction to deliver
Barber (2007) whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’Instruction to Deliver

  • Awful  adequate

    • Command & control

      • public not satisfied

      • have to keep flogging the system

  • Adequate  good / great

    • quasi market & consumer choice

      • innovation from self-sustaining systems


The impact of the nhs market an overview of the literature
The impact of the NHS market: An overview of the literature* whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • No good evidence reforms produced beneficial outcomes classical economic theory predicts of markets

     provider responsiveness to patients & purchasers

    large-scale cost reduction

    • innovation in service provision

  • NHS incurs transaction costs of market without benefits

* Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf


System reform package commmissioning
System reform package & commmissioning whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

No


Questions
Questions whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • Change

    • Devolution  worse performance in devolved countries?

  • Selection

    • Purchaser / provider split?

    • ‘World Class Commissioning’?

    • Patient choice?

  • Reputation

    • Executive  democratic accountabilty?


References
References whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • Audit Commission & Healthcare Commission. Is the treatment is working? <http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=9F8B7F6A-214D-4165-BE65-716315270A82&fromREPORTSANDDATA=NATIONAL-REPORT>

  • Auditor General for Wales (2005) NHS waiting times in Wales. Volume 2 - Tackling the problem. <http://www.wao.gov.uk/reportsandpublications/2005.asp>

  • Bevan (2006) Setting Targets for Health Care Performance: lessons from a case study of the English NHS. National Institute Economic Review, 197, 67-79.


References1
References whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • Bevan (2010) Approaches and impacts of different systems of assessing hospital performance. Journal of Comparative Policy Analysis, 2010, 12(1 & 2): 33 – 56

  • Bevan & Hamblin (2009) Hitting and missing targets by ambulance services for emergency calls: impacts of different systems of performance measurement within the UK. Journal of the Royal Statistical Society (A), 172(1):1-30.

  • Bevan & Hood (2006) Have targets improved performance in the English NHS? British Medical Journal, 332, 419-422.

  • Bevan & Hood (2006) What’s Measured is What Matters: Targets and Gaming in the English Public Health Care System. Public Administration 84, 3, 517-38.

  • Chassin (2002) Achieving and sustaining improved quality: Lessons from New York State and cardiac surgery. Health Affairs, 21(4), 40-51.


References2
References whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • Fung et al (2008) Systematic review: The evidence that publishing patient care performance data improves quality of care. Annals of Internal Medicine, 148, 111-123.

  • Hibbard (2008) What can we say about the impact of public reporting? Inconsistent execution yields variable results. Annals of Internal Medicine, 148, 160 - 161.

  • Hibbard et al (2003) Does publicizing hospital performance stimulate quality improvement efforts? Health Affairs, 22 (2), 84-94.

  • Hibbard et al (2005) Hospital performance reports: impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-60.


References3
References whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • House of Commons Health Committee (2010) Commissioning. (Fourth Report of Session 2009–10, Volume I) HC 268-I. London: The Stationery Office Limited. < http://www.parliament.the-stationery-office.co.uk/pa/cm200910/cmselect/cmhealth/268/26802.htm>

  • Mannion et al (2005) Impact of star performance ratings in English acute hospital organisations. Journal of Health Services Research & Policy, 10 (1), 18–24.

  • Mannion & Goddard (2001) Impact of published clinical outcomes data: case study in NHS hospital organisations. BMJ, 323, 260 – 263.


References4
References whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

  • Mannion & Goddard (2003) Public disclosure of comparative clinical performance data: lessons from the Scottish experience. Journal of Evaluation in Clinical Practice, 9 (2), 277–286

  • Marshall et al (2000) The Public release of performance data: What do we expect to gain? A review of the evidence. Journal of the American Medical Association, 283(14), 1866-1874.


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