Levers for change in healthcare systems: The role of performance measurement and reporting

Levers for change in healthcare systems:The role of performance measurement and reporting

Jean-Frederic Levesque, MD, PhDChief Executive Officer, Bureau of Health InformationConjoint Professor, Centre for Primary Health Care and Equity, UNSW

27 August 2015

Levers for change in healthcare systems: The role of performance measurement and reporting – 27 August 2015

Healthcare systems are complex and supporting them with knowledge is as fundamentalas it is challenging

Levesque, Sutherland & Corscadden 2013


Concepts

Knowledge organisations

Enablement

Insights

1

2

3

4


What do we mean byPerformance?Knowledge?Enablement?

1


Performance happens when structures, resources, providers and patients interact in real contexts

Levesque, Sutherland & Corscadden 2013


Hollnagel, Braithwaite & Wears 2013

The difference between theory and practice is larger in practice than in theory


If actors perform on stage, athletes perform on the field,surgeons perform in surgical theatres and nurses perform at the bedside or in community centresLevesque, Sutherland & Corscadden 2013


Knowledge

Information

Data

Action

Change


DataData represents the codification of real phenomena into a form that can be analysed


InformationData becomes informationby interpretation


KnowledgeKnowledge signifies understanding of real things or abstract concepts that data and information have enabled to decipher and analyse


AccessibilityPrevalence

Avoidable deaths

Unmet needs Adverse events

Quality of life

High users

Duplications

Health risks

Team climate

Health literacyDisability

Hospital mortality

Costs

Safety

ResourcesSatisfaction

Coordination


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 changeLeatherman 2002


ActionKnowledge supports action through behaviour and decisions


ChangeHealthcare systems constantly change in terms of structures, processes and their outcomes


Peer learning

HugTraining

BenchmarkingRegulation

Continuous education

Pay for outcomes

Pay for performance

Quality improvement

Awareness

Self-regulation

Peer-pressure

Monitoring

Incentive

Judge

Provider feedback

Cross-fertilisation

Nudge

Contract management

Monitoring

Shove

Push


planned

emergent

internal external

supportive

formative

coercive

normative

structural

competitive

cognitive

mimetic


Multimodal approaches have the biggest impactOECD 2002



Australian Commission for Safety and Quality in Healthcare

National Health Performance Authority (NHPA)

Independent Hospital Pricing Authority

UK Care Quality Commission The King’s Fund

The Nuffield Trust

Dr Foster

RAND Corporation

Centres for Medicare and Medicaid Services (CMS)

Agency for Healthcare Research and Quality (AHRQ)

USA Institute for Health Improvement

Ambulatory Care Quality Alliance (AQA) Hospital Quality

Alliance (HQA)Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

National Committee for Quality Assurance (NCQA)

National Quality Forum (NQF)

Physician Consortium for Performance Improvement (AMA)

Leapfrog Group

Bureau ofHealth Information (BHI)

USA Accountable Care Organisation

Quebec’s Health and Welfare Commissioner

La haute autoritéde santé France

Canadian Institute of Health Information

Ontario Care Quality Council


Goals pursued and national context influence the mix of health system stewardship functions required to achieve health system goalsVeillard 2012


Knowledgeorganisationsin New South Wales

2






BHI reports• Annual performance report

• Hospital Quarterly

• Insights into Care

• Patient Perspectives

• Snapshots, briefs, dashboards and profiles


Garling Report

The public reporting of information about the health system and hospital performance is essential for the future of NSW Health. It is the single most important driver (or lever) for the creation of public confidence in the health system, engagement of clinicians, improvement and enhancement of clinical practice and cost efficiency.







Using information to enable performance in New South Wales

3


Coercive and cognitive leversThe example of hospital timeliness performance measures


Percentage of patients leaving in four hours – hospitals


Time from presentation to treatment – NSW


planned

emergent

internal external

supportive coercive

cognitive

competitive


Normative and supportive leversThe example of mortality


30-day mortality following hospitalisation


30-day mortality following hospitalisation – hospital outliers


planned

emergent

internal external

supportive

normative

cognitive

mimetic


Normative and structural leversThe example of Cancer ED performance measures


ED use at the end of life – NSW


ED use for cancer patients – hospital outliers


planned

emergent

internal external

normative

structuralcognitive


Insights from the NSW experience

4


No organisation can use all levers all the time…some levers are synergistic, some are in tension


Small organisations are more agile and responsive… lack economies of scale and depth of resources


Specialisation brings focus and concentration of expertise…brings the risk of fragmentation and duplication


Splitting and overlapping responsibilities enable emulation, competition and diversity andbrings resilience


Multiple organisationscan create confusion and impose burdens on stakeholders


A knowledge organisation acts in a negotiated space


Concepts

Knowledge organisations

Enablement

Insights

1

2

3

4


planned

emergent

internal external

supportive

formative

coercive

normative

structural

competitive

cognitive

mimetic

Knowledge

Information

Data

Action

Change


Thank you!

Levers for change in healthcare systems: The role of performance measurement and reporting

Health & Medicine