International Journal for Quality in Health Care 15:i3-i4 (2003)
© 2003 International Society for Quality in Health Care
Statement From ISQua |
ISQua’s 4th International Summit on Indicators, Buenos Aires, October 2001
Chief Executive Officer, The International Society for Quality in Health Care (ISQua)
ISQua, The International Society for Quality in Health Care, works to provide services to guide health professionals, health providers, researchers, agencies, policy makers and consumers to achieve excellence in healthcare delivery to all people and to continuously improve the quality and safety of care. ISQua is a global, not for profit, voluntary, open membership organization. In 2001, it had members in over sixty countries.
Performance measurement with feedback is generally acknowledged as an important methodology in facilitating improvement in quality in health care. Some months before the Buenos Aires Indicators Summit, ISQua’s Executive Board confirmed the Society’s on-going interest in pursuing the development of global interest in indicators of patient care and an ISQua program of work to achieve and manage this. ISQua had observed a mushrooming of interest around the world in the development of performance measures and other types of indicators. This was felt to be consistent with worldwide trends towards the measurement of processes and outcomes which can lead to performance improvement.
The words ‘performance indicator’, ‘clinical indicator’ or just ‘indicator’ were seen by ISQua’s Indicators Steering Committee as interchangeable in use. For the Buenos Aires program, a clinical indicator was defined as ‘a flag or measure of the clinical management and/or outcome of care’. In this definition the term ‘clinical’ refers to all members of the clinical team. The ISQua leadership and the Indicators Steering Committee also referred to indicators as ‘measures of health system performance’.
The Buenos Aires Summit was the fourth international ISQua meeting on Indicators. In 1998, in Budapest, with the guidance of a small planning group, ISQua initiated the first international meeting on this topic. Nearly 50 delegates from twenty countries were involved in a fact-finding session at which they considered aligning indicators and related processes at an international level and how this could be achieved. This meeting was an important beginning to a major new international initiative for the Society.
The second meeting in Melbourne in 1999 attracted over 100 delegates and a draft set of ‘Principles for the Development of Indicators’ was agreed as a working document (see interim Principles List below).
In Dublin 2000, at the third meeting, presentations covered many ideas about Indicators work. In 2001 the ISQua Executive Board agreed that it was timely to have a more specific focus for the Buenos Aires meeting and to resolve feasible directions. The program therefore proceeded from a more general discussion of indicators to focus more specifically on indicators for patient safety.
The impact of the events of September 11 in the US reduced attendance at the Buenos Aires Summit, however, 60 people from 22 countries attended; simultaneous Spanish translation was provided.
ISQua has the unique position and capacity to draw together diverse perspectives on indicators from across the globe. The Executive Board considers that this can continue to expand with the assistance of key organizations in the field. This would include agencies such as the OECD, WHO and other global and regional indicator initiatives.
Associate Professor Haya Rubin at Johns Hopkins University, USA, was asked to assist with leading the special two-day pre-conference Summit in Buenos Aires and obtained a conference support grant from AHRQ (Agency for Healthcare Research & Quality), to be administered by Johns Hopkins School of Medicine. The grant proposal indicated that an important outcome planned from the Summit would be the publication of a special supplement to the International Journal for Quality in Health Care.
We thank Dr Rubin for her efforts in achieving an excellent Summit program over the two days, some of which had to be revised very much at the last minute, and for Guest Editing this Journal supplement that presents papers by the Summit speakers.
ISQua places on record its warm appreciation for the AHRQ support provided via Johns Hopkins University towards the success of its 4th International Summit.
ISQua’s interim principles for quality indicators (1999)
- Indicators will provide a quantitative basis for clinicians, provider organizations and planners aiming to achieve improvement in care and the processes by which patient care is provided.
- Areas addressed by indicators will be of clinical significance and usefulness; i.e. they:
- will focus on a significant clinical burden for a defined population
- will refer to serious disorders or a serious complication of a major procedure
- may have a cost-related burden
- will focus on a significant clinical burden for a defined population
- Indicators must be precisely defined; i.e. the resultant quantitative data must:
- relate to clearly identifiable events
- be based on agreed definitions which can be uniformly implemented
- have specificity and be evidence-based
- be valid and reliable, i.e. based on a process of validation and reliability testing
- be risk-adjusted to enable comparisons
- be interpreted in the light of local socio-economic and cultural issues
- permit useful comparisons across like entities, e.g. clinicians in the same speciality
- be well tested and validated, if they are eventually to be publicly available
- relate to clearly identifiable events
- There will be some degree of provider involvement in the development of indicators; i.e.:
- There will be a degree of ownership reflected in the development and use of indicators,
- Indicators will be widely acceptable, i.e. non-controversial as measures and will address recognized treatments or procedures,
- Indicators will be responsive, i.e. the information received will prompt action by providers to improve a process and/or outcome,
- There will be ease of data extraction, and
- The indicator process will not violate any accepted forms of patient confidentiality.
- There will be a degree of ownership reflected in the development and use of indicators,
- There will be an effective and regularly applied process of indicator evaluation and review which will incorporate changes over time. The process will include:
- indicator measure evaluation and refinement
- system evaluation and refinement
- timely feedback processes
- indicator measure evaluation and refinement
Constraints on the availability of appropriate data have an impact on any indicator developments. As the perceived value of indicators will increase over time, the need for reliable guidelines to be available via organizations such as ISQua will also increase.
Increasing demand from governments for indicators of ‘organization’ performance for public accountability and reporting is understood to be a different issue and to have different measurement implications from those of indicators for internal use in relation to quality improvement.
Points raised in discussions have also included:
- The need to avoid situations where indicators may be limited to cover only high risk, high cost situations which are often rare conditions. In contrast, there are conditions which while not at high risk of causing death or severe disability or of incurring high clinical cost, are nevertheless burdensome to a whole population and involve considerable community cost.
- The importance of public release of information after it has been carefully validated. While many individual physicians, for example, would welcome internal data to assist them with evaluation and improvement of their own care of patients, there would be a much more reserved reaction to determining which indicator data reflecting process and outcomes of health care provision should be provided to health plans or to the public. Individual practice accreditation systems are already being linked to performance measurement and tied to financial reward.
- The importance of interpreting indicators in the light of local socio-economic and cultural influences was emphasized. There is a strong emphasis on the need for reliable, validated data without which performance indicators have little meaning.
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