This presentation by the Bureau of Health Information to the Royal Australasian College of Physicians looks at using clinical outcome data to improve patient care. It examines: Why measure and report on performance? - Accountability and quality improvement What is performance really? - It is not a measure of what the system is, it is a measure of how well the system does Whose performance is it anyway? - Attributing results to providers, units or sectors requires a careful assessment

1. Jean-Frederic Levesque
Chief Executive
Using Clinical Outcome Data
to Improve Patient Care
3June2014
NSWStateOfficeCPDEvent
TheRoyalAustralasianCollegeofPhysicians

2. Outline of the presentation
• Why measure and report on performance?
• Accountability and quality improvement

3. Outline of the presentation
• Why measure and report on performance?
• Accountability and quality improvement
• What is performance really?
• It is not a measure of what the system is, it is a
measure of how well the system does

4. Outline of the presentation
• Why measure and report on performance?
• Accountability and quality improvement
• What is performance really?
• It is not a measure of what the system is, it is a
measure of how well the system does
• Whose performance is it anyway?
• Attributing results to providers, units or sectors requires
a careful assessment

5. Why measure and report
on performance?

6. National Health Performance Authority
Canadian Institute of Health Information
UK Care Quality Commission
USAInstitute for Health Improvement
Ontario Quality Council
La haute autorité de santé France
USA Accountable Care Organisation
Quebec’s Health and Welfare Commissioner
Bureau of Heath Information

7. “I am firmly convinced that the public reporting of
information about the health system and hospital performance
is essential for the future of NSW Health.
The Garling Report

8. “I am firmly convinced that 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.”
The Garling Report

9. The Bureau’s purpose
To provide the community, healthcare professionals and
the NSW Parliament with independent, timely and accurate
information about the performance of the NSW public health
system in ways that enhance the system’s accountability and
inform efforts to improve health care.

10. Reporting to promote accountability
• Patient empowerment
• Supporting patients’ choices and expectations
• Promotes accountability at the patient-provider interface
• Political debate
• Stimulating explicit debates about policies
• Supports a culture of openness about performance

11. Reporting to support improvement
• Internal motivation
• Knowing about own performance is a starting point
(cognitive)
• Seeing the performance of others reinforces (mimetic)
• External pressure
• Contracts, funding streams and policies (regulatory)
• Peer judgement and public pressure (normative)

12. Healthcare in Focus – Annual Performance Report
Aim: takes a wide-ranging look at
the NSW health system, examining
performance within Australia and in
comparison with other countries

13. Insights into Care
Aim: explores information about
specific topics in patient care and
identifies opportunities to improve
the healthcare system

14. Patient Perspectives
Aim: provides information about
what patients are saying about
their healthcare experiences

16. What is performance really?

17. Quality of Care
Patients participation and engagement
Efficiency and value for money
Adverse events and complications
Staff morale and stability
Respectfulness and dignity
Continuity of care and coordination
Conformity to clinical guidelines
Performance of healthcare

18. A definition of performance
Performance refers to the actual production or enactment of a
function. Actors perform on stage. Athletes perform in
competitions. Surgeons perform in operating theatres.

19. A definition of performance
Performance refers to the actual production or enactment of a
function. Actors perform on stage. Athletes perform in competitions.
Surgeons perform in operating theatres.
In health care systems, performance refers to the provision of
expected volumes and quality of services that meets the
populations needs and expectations given the amount of
resources invested.

20. An integrated model of performance measurement

21. Clinically-relevant dimensions of performance
• Productivity
• Accessibility
• Appropriateness
• Effectiveness

22. Productivity : being organised, doing more

23. Productivity : being organised, doing more
Measurements of primary
care volumes of services
per resources invested:
human and financial
resources

24. Maximising ambulance transportation

25. Accessibility: healthcare where and when needed

26. Accessibility: healthcare where and when needed
Proportion of patients seen within
a specified time after presenting to
the emergency department
Proportion of people not seeking
healthcare because of cost

28. Appropriateness: The right healthcare, the right way

29. Appropriateness: The right healthcare, the right way
Proportion of chronic disease patients
receiving recommended care
Proportion of patients reporting not
being as involved as they wanted to be
in decisions about their care

30. Appropriateness – technically proficient
Medical Errors In the past two years, have you experienced?

31. Appropriateness – patients’ experience of care

32. Effectiveness: making a difference for patients

33. Proportion of patients that
report they were helped by
the care they received
Rates of complications
from surgical or medical
procedures
Effectiveness: making a difference for patients

34. Hospitals with higher than expected results

35. 30-Day Mortality: Mortality in hospital following discharge

38. Hospital profile: Dashboard

39. Hospital profile: in context

40. Policy-relevant dimensions of performance
• Efficiency
• Equity
• Sustainability
• Impact

41. Whose performance is it anyway?

42. Dashboards
Clinical and provider assessments
Anonymised reports
Balanced scorecard
Audit and clinical competency
System and organisational perspectives
Key performance indicators and targets
Ranking of hospital facilities
Reporting on performance

43. Some challenges of attribution
• Performance is a nested process, enacted at the levels
providers, organisational and system levels
simultaneously

44. Some challenges of attribution
• Performance is a nested process, enacted at the levels
providers, organisational and system levels simultaneously
• Performance is a shared process in a context of complex
diseases management processes

45. Some challenges of attribution
• Performance is a nested process, enacted at the levels
providers, organisational and system levels simultaneously
• Performance is a shared process in a context of complex
diseases management processes
• Resources, processes and outcomes do not happen in
the same timescales and indicators are limited in their
capacity to capture temporal relationships

46. Some challenges of attribution
• Performance is a nested process, enacted at the levels
providers, organisational and system levels simultaneously
• Performance is a shared process in a context of complex
diseases management processes
• Resources, processes and outcomes do not happen in the
same timescales and indicators are limited in their capacity to
capture temporal relationships
• Outcomes are more relevant, a reflection of the ultimate
goals of systems – outcomes are less attributable,
results of multiple influences outside the healthcare
systems

47. Enhancing attribution potential
• Relating measures of needs, resources, processes and
outcomes to derive true constructs of performance

48. Enhancing attribution potential
• Relating measures of needs, resources, processes and
outcomes to derive true constructs of performance
• Focusing on clinically relevant and specific measures of
outcomes

49. Enhancing attribution potential
• Relating measures of needs, resources, processes and
outcomes to derive true constructs of performance
• Focusing on clinically relevant and specific measures of
outcomes
• Clustering of measures related to a specific sector

50. Enhancing attribution potential
• Relating measures of needs, resources, processes and
outcomes to derive true constructs of performance
• Focusing on clinically relevant and specific measures of
outcomes
• Clustering of measures related to a specific sector
• Controlling for confounders
• Presenting true performance by peer groups –
highlighting true variations within groups/peers
• Presenting adjusted results – highlighting adjusted
variations controlling for case-mix/context

51. Acknowledgements
• Kim Sutherland, Director, System and Thematic Reports,
Bureau of Health Information
• Lisa Corscadden, Senior Researcher, Bureau of Health
Information
• Efren Sampaga, Graphic designer, Bureau of Health
Information
• All BHI staff