health system performance management quality for better or for worse
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Niek Klazinga, April 27 2010 London LSE/NHS Confederation. Health System Performance Management quality for better or for worse. Accountability Strategic decision making Learning/improvement. Reasons for international comparisons on performance related to quality of care.

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reasons for international comparisons on performance related to quality of care

Strategic decision making


Reasons for international comparisons on performance related to quality of care

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

measurement and management
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
health systems performance management
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
related policies
Related policies
  • Health system sustainability
  • Integrated care
  • Prevention
  • Patient Centered Care
  • Equity
  • Regulated market
  • Incentive structures

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.



Combining various rationalities

  • Public Health
  • Medicine
  • Management sciences
  • Economics
  • Societal / individual values
performance indicators and benchmarking related to mortality data
avoidable mortality (health system level)

standardized mortality rates (hospital level)

limitations of death statistics

Performance indicators and benchmarking related to mortality data

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)

performance indicators and benchmarking related to cancer care


Limitations of cancer registries and limited possibilities for linking with other (administrative) data-bases

Performance indicators and benchmarking related to cancer care
performance indicators and benchmarking on care delivered in hospitals
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
  • 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)


performance indicators in primary care
Avoidable hospital admissions

Lack of comprehensive administrative data-sets

Performance indicators in primary care
avoidable hospital admission rates 2007
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

patient experiences
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
limitations national information infrastructures
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
national information infrastructures
National Information Infrastructures

Mortality statistics

Registries (cancer)

Administrative Databases

Electronic Health Records




UPI’s, present-at-admission codes, secondary diagnoses

Standardized secondary data-use, privacy concerns



Clinical guidelines

Performance indicators

Patients’ safety




Audit and internal assessment

Patients’ views

1.2. Analysis of strategies


Exploratory Factor Analysis

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