Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia

Abstract

This article describes recent national performance improvement initiatives in the United States, United Kingdom, and Australia. This comparison is of particular interest because each of these three countries faces similar challenges in delivering health care and improving health. Each has elevated a focus on safety and quality improvement to a national level. Marked differences in the organization and financing of health care across these three countries provide a unique opportunity to compare and contrast approaches. Drawing on the experience of the authors in each of the three countries and publicly available data sources about specific national initiatives, we describe the national context for improvement and outline recent performance improvement initiatives and emerging issues and challenges. Similarities and differences in the current evolution of national performance initiatives are described and conclusions are drawn about challenges that all three countries face, particularly in terms of developing meaningful sets of national indicators of health system performance. The challenges for future work include the importance of information infrastructure, the paucity of accurate and accessible clinical data, the need for effective performance measurement processes at a local level to capture useful data, and the tensions of balancing accountability and improvement agendas for measurement.

Performance Measurement in Healthcare: Part II - State of the Science Findings by Stage of the Performance Measurement Process

“…Even so, Nutley and Smith (1998: 53) contend that "calls for a top to bottom PM architecture have largely been ignored." Others caution that the PM for highlevel management and accountability differs from that needed for daily operations (McLoughlin et al 2001;Voelker et al 2001).…”

“…Administrative data have long been considered a rich source for PM if properly "mined," and researchers in particular have produced notable examples of their creative and rigorous use (e.g., Brownell et al 2001). But many now suggest that the value of secondary data has been overstated, at least as typically formatted (Bishop and Pelletier 2001;McLoughlin et al 2001). Problems cited include poor reflection of performance, lack of data elements for sensitive diagnosis and risk adjustment, lack of availability and stability of data at smaller levels of aggregation and generally poor quality (Kelman and Smith 2000; Brown 2002).…”

“…Many advocate for routine prospective data collection, fully integrated with clinical practice, that can be used for the delivery of care as well as rolled up for management use (McLoughlin et al 2001). Concerns remain about the diversion of clinician time from patient care to data recording tasks (Naylor 1999).…”

Measuring quality

“…A recent discussion by McLoughlin et al highlighted the differences between the Australian, US and UK health systems. 25 While the United Kingdom is characterised by a centralised system which aims to assess quality from a national perspective, the United States operates through a market-driven service comprised of independent private sectors propelled by consumer satisfaction. In contrast, Australia has a mixed public/private funding model.…”

“…28 In Australia, continued difficulties in obtaining reliable and valid clinical data, as well as providing a national set of quality indicators meaningful to all, continue to plague quality measurement. 25 …”