Applying Indicators to Improve Health System Performance

The cycle of performance measurement and management begins with explicitly establishing goals which are reflected in the adoption of specific performance indicators, followed by analysis and actions aimed at producing change to improve performance in a variety of dimensions such as equity, access, effectiveness, efficiency and social responsiveness. The application of performance indicators may involve simply reporting data to actors for accountability purposes, or it may involve, in addition, taking action to stimulate change. This paper will first summarize some evidence on the use and impacts of public release of health care performance data, based largely on the American experience (as described in “Dying to know: Public Release of Information about Quality of Health Care” by Marshall et al., co-published by The Nuffield Trust and Rand, 2000). Some of the main conclusions from this review of evidence from the United States are that: first, currently available report cards are rarely read by individual consumers, and do not seem to have much influence on their decisions to choose health care providers; but second, and although physicians and provider organisations tend to be critical of performance reports, provider organisations seem to be the most responsive to publicly disclosed data. The paper will then outline a further range of levers that might be used to try to improve performance, where available indicators suggest room for improvement. A careful diagnosis of the underlying causes of problems in the health care system is needed to select the appropriate intervention. Furthermore, the levers for change will vary among countries (or even within different health care systems in the same country) depending upon factors such as underlying values, financing and organisational arrangements, professional culture, and the self-perception of the citizenry as active or passive participants in health care interactions. The selection of the intervention will depend upon who/what is the intended target for behavioral change, for example providers (individual or institutional), professional bodies, citizens, or managers. Though identifying a “best method” to effect change may not be realistic, this paper will identify a range of possible approaches, discuss their strengths and limitations, and (where possible) describe relevant country experiences. Possible approaches, grouped within five categories, will be discussed: 1. External oversight – External review/inspection * President, Center for Health Care Policy and Evaluation; Adjunct Professor, School of Public Health, University of North Carolina; Senior Advisor, The Nuffield Trust, London, England; Sr. Associate, Judge Institute of Management Studies, University of Cambridge, England. Mailing Address: Center for Health Care Policy and Evaluation, MN008-W105, PO Box 1459, Minneapolis, MN 55440, Phone: 952-936-7373, Fax: 952-936-3048, [email protected]. Measuring Up: Improving the Performance of Health Systems in OECD Countries