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Health System Performance Management quality for better or for worse

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quality for better or for worse Niek Klazinga, April 27 2010 London LSE/NHS Confederation Performance indicators and benchmarking related to mortality data avoidable ... – PowerPoint PPT presentation

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Title: Health System Performance Management quality for better or for worse


1
Health System Performance Management quality for
better or for worse
  • Niek Klazinga, April 27 2010
  • London LSE/NHS Confederation

2
Reasons for international comparisons on
performance related to quality of care
  • Accountability
  • Strategic decision making
  • Learning/improvement

3
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
4
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

5
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)

6
Related policies
  • Health system sustainability
  • Integrated care
  • Prevention
  • Patient Centered Care
  • Equity
  • Regulated market
  • Incentive structures

7
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.15-13.
7
8
Combining various rationalities
  • Public Health
  • Medicine
  • Management sciences
  • Economics
  • Societal / individual values

9
Performance indicators and benchmarking related
to mortality data
  • avoidable mortality (health system level)
  • standardized mortality rates (hospital level)
  • limitations of death statistics

10
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)
11
Performance indicators and benchmarking related
to cancer care
  • CONCORD study
  • Eurocare
  • Limitations of cancer registries and limited
    possibilities for linking with other
    (administrative) data-bases

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18
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 UPIs
  • Limitations Electronic Health Records

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23
Patient Safety Indicators
  • Indicators based on administrative databases
  • Adverse event reporting
  • Safety culture

24
Indicators
  • 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)

24
25
Performance indicators in primary care
  • Avoidable hospital admissions
  • Lack of comprehensive administrative data-sets

26
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
27
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

28
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

29
National Information Infrastructures
  • Mortality statistics
  • Registries (cancer)
  • Administrative Databases
  • Electronic Health Records
  • Surveys
  • UPIs/co-morbidity
  • UPIs/coding-staging
  • UPIs, present-at-admission codes, secondary
    diagnoses
  • Standardized secondary data-use, privacy concerns
  • UPIs

30
Hospital Level Hospital Level Hospital Level
Q.I. Strategies Q.I. Strategies Q.I. Strategies

Ward Level Ward Level Ward Level
AIM Deliveries Appendicitis
QI Strategies QI Strategies QI Strategies
Outputs Outputs Outputs
1.2. Analysis of strategies inter-connection
Exploratory Factor Analysis
Strategies Loading weights
- Patient Safety Systems - TQM - Performance Indicators - Systems for getting Patients Views - Clinical guidelines .857 .822 .694 .581 .578
31
Health System Performance Management
  • Whole system approach
  • Sub-optimization
  • Governance/stewardship
  • Incentive structure
  • Interconnection of strategies on performance
    indicators, guidelines, safety, TQM, patient
    experiences
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