International Journal for Quality in Health Care Advance Access originally published online on March 13, 2008
International Journal for Quality in Health Care 2008 20(3):162-171; doi:10.1093/intqhc/mzn008
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An international review of projects on hospital performance assessment
1 Research and Education, Avedis Donabedian Research Institute, Barcelona, Spain
2 CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
3 Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
4 Bispebjerg Hospital, Copenhagen, Denmark
Address reprint requests to: Jutta K. H. Skau, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen K, Denmark. E-mail: jskau{at}stud.ku.dk
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Abstract |
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Background. Assessing the quality of health care has become increasingly important in health care in response to growing demands from purchasers, providers, clinicians and the public. Given the increase in projects and programs to assess performance in health care in the last 15 years, the purpose of this paper is to review current indicator projects for hospital performance assessment and compare them to the Performance Assessment Tool for Quality Improvement in Hospitals (PATH), an initiative by the WHO Regional Office for Europe.
Methodology. We identified current indicator projects through a systematic literature search and through contact with experts. Using an inductive approach based on a review of the literature, we identified 10 criteria for the comparison of indicator projects. We extracted data and contacted the coordinators of each indicator project to validate this information. In addition, we carried out interviews with coordinators to gather additional information on the evaluation of the respective projects.
Results. We included 11 projects that appear to have adopted a common methodology for the design and selection of indicators; however, major differences exist with regard to the philosophy, scope and coverage of the projects. This relates in particular to criteria such as participation, disclosure of results and dimensions of hospital performance assessed.
Conclusion. Hospital performance assessment projects have become common worldwide, and initiatives such as the WHO PATH project need to be well coordinated with existing projects. Our review raised questions regarding the impact of hospital performance assessment that should be pursued in further research.
Keywords: quality improvement, quality management, quality indicators, measurement of quality
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Introduction |
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Assessing the quality of health care has become increasingly important for different stakeholders such as health care providers, decision makers and purchasers of health care in response to growing demands to ensure transparency, control costs and reduce variations in clinical practice [1]. While 10–15 years ago hospital performance assessment was an innovative field [2], many projects are now operational in European countries and worldwide [3]. In addition, several initiatives are being supported by international organizations as World Health Organization (WHO) and Organization for Economic Co-operation and Development (OECD) [4, 5]. However, the goals and strategies of these projects are very diverse and national projects from different countries pursuing similar objectives may adopt strategies that are based on fundamentally different philosophies regarding participation in the project and disclosure of results [6]. It is, therefore, of interest to focus on the effects of different strategies for quality improvement, a question which is also addressed by a current research project supported by the European Commission [7]. Furthermore, with the creation of national initiatives for hospital performance assessment in many countries, the added value of international projects needs to be evaluated.
Therefore, the purpose of this paper is to review current indicator projects on hospital performance assessment and compare them with the Performance Assessment Tool of quality improvement in Hospitals (PATH), which is an international initiative coordinated by the WHO Regional Office for Europe aiming to support hospitals in assessing their performance, questioning their own results and translating them into actions for improvement [5]. This comparison was also carried out in order to assess the possible overlaps and competition in hospital performance initiatives and identify approaches for an evaluation of performance assessment projects. Based on the comparative review, we discuss differences in the perspectives and strategies of these projects with a particular focus on the approach towards a possible evaluation of performance indicator projects in the future.
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Methodology |
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Identifying hospital performance assessment projects
We carried out a systematic literature search in PUBMED to identify current and relevant hospital performance assessment projects, applying the following search strategy: (i) Indicator* OR stand*, (ii) qualit*, (iii) hospital performance, (iv) project* OR program* OR tool* and (v) measure* OR assessm*. We included articles in the search that were published in English after 1995 and found 73 relevant hits. After the initial screening, we identified 14 articles on 10 different projects. This list was then reviewed by a researcher in the Methods of Assessing Response to Quality Improvement (MARQuiS) project [8] who provided information on 18 additional projects from 13 countries. These projects were not included in the final analysis as no additional information was available in publicly accessible sources. Moreover, they could not be characterized as independent projects as the others in the analysis, but rather being some side-activity of another quality program.
Identification of criteria
We determined the criteria to compare the projects using an inductive approach. This consisted of exploring the relevant literature, documents and websites of the identified projects and highlighting information reflecting the design of the project. Moreover, we put a particular focus on identifying criteria on the evaluation of these projects. We then sought comprehensive definitions for each criterion, if possible, based on the Medical Subject Heading (MeSH) or other definitions that were consented by respected quality agencies. A description of the final list of criteria that were used for the comparative analysis is presented in Table 1.
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Validation
After the information was collected, we contacted each project coordinator and asked them to validate the information we had obtained. Furthermore, we carried out short telephone interviews with project coordinators from 8 of the 10 indicator projects to gather additional information and opinions on evaluation of indicator projects. Interviews lasted a maximum of 15 min, were recorded on Dictaphone and subsequently transcribed for the comparative review. The final results were once again validated by the project coordinators.
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Results |
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Overall, 11 hospital performance indicator projects were included (10 national projects and PATH) for a comparative review according to the 10 criteria described above (see Tables 2–4). Abbreviations used in the following, and links for further information, are included in Box 1.
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| Box 1. Abbreviations and relevant websites ACHS Australian Council on Health care Standards, http://www.achs.org.au BQS Bundesgeschäftsstelle Qualitätssicherung, http://www.bqs-outcome.de CIST Clinical Indicators Support Team, NHS Quality improvement Scotland, http://www.indicators.scot.nhs.uk
COMPAQH COordination pour la Mesure de la Performance et IQIP International Quality Indicator Project, http://www.internationalqip.com JCAHO Joint Commission Accreditation of Health Care Organization, http://www.jointcommission.org MARQuiS Method of Assessing Response to Quality Improvement Strategies, http://www.marquis.be NIP The National Indicator Project, http://www.nip.dk OAH Ontario Hospitals Association, http://www.oha.com OECD Organization for Economic Co-operation and Development PATH The Performance Assessment Tool for Quality Improvement in Hospitals: www.pathqualityproject.eu QIP Quality Indicator Project, http://www.qiproject.org The Dutch project on reporting of performance in hospitals, http://www.rivm.nl/ Verein Outcome: www.vereinoutcome.ch WHO World Health Organization, http://www.euro.who.int
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In the following, we highlight the results for each column presented in Tables 2–4.
Assessing the performance of hospitals appears to be a relatively new area in the field of health sciences and hospital management in Europe, as only four non-European projects (ACHS, JCAHO, OHA and QIP) and CIST Scotland (though in a different organizational structure) were launched before 2000. COMPAQH, the Dutch project on reporting of performance in hospital, and PATH are some of the most recent projects, being initiated in 2003. None of the projects covered all dimensions of the PATH project. However, Clinical effectiveness was covered by nine other projects (ACHS, CIST, COMPAQH, BQS, JCAHO NIP, QIP, Verein Outcome, the Dutch project on reporting of performance in hospitals). Except PATH, the domain of Staff orientation was covered by only one project (COMPAQH). During the interviews, it became clear that the performance dimensions are defined very heterogeneously, and there appears to be no consensus on the conceptual demarcation of efficiency and clinical effectiveness.
The number of indicators for each project ranges from 36 (JCAHO) to >300 (ACHS) indicators. PATH can be distinguished here from other projects as it contains a set of core indicators, which need to be collected by all hospitals, and tailored indicators, which can be chosen by hospitals based on capacities, interests and appropriateness to the context. Some national projects divide indicators into subject areas, but due to the lack of consensus on concepts it is difficult to compare these subject areas.
All the projects used expert groups, e.g. different stakeholders (clinical staff, hospital management, insurance companies) in the primary phase of developing the indicators. The expert groups contributed to the scientific analysis as well as systematic literature reviews and rating/consensus methods, such as Delphi method or nominal group techniques. It is not clear to what extent indicators are assessed by each project in terms of their psychometric properties. Projects differ in the extent to which users such as health professionals and managers on the one hand and patients and citizens on the other were involved in the selection and design of indicators.
Five projects are based on voluntary participation (ACHS, COMPAQH, OAH, QIP and PATH), whereas five projects are based on non-voluntary participation (CIST Scotland, BQS, JCAHO, NIP and the Dutch projects on reporting of performance in hospitals). Verein Outcome contains both non-voluntary and voluntary participation. The coverage of the projects ranges from 43 (COMPAQH) hospitals to 9935 hospitals (JCAHO). All projects use a combination of routine data and prospectively collected data for the analysis. Eight projects also use indicators that are based on surveys (ACHS, COMPAQH, JCAHO, OAH, QIP, Verein Outcome, the Dutch projects on reporting of performance in hospitals and PATH), and only three projects construct indicators based on audits (QIP, NIP and PATH). The results of the data analysis are available to the public in five projects (CIST Scotland, NIP, JCAHO, Verein Outcome and the Dutch projects on reporting of performance in hospitals); for six projects, only providers have access to the results (ACHS, COMPAQH, BQS, OAH, QIP and PATH).
In terms of feedback mechanisms, the projects apply similar tools such as websites, newsletters, annual reports, scientific articles etc. Seven projects use workshops as an educational feedback loop (ACHS, CIST Scotland, COMPAQH, JCAHO, NIH, QIP and Verein Outcome). There are major differences though with regard to the reported feedback time, and the range of responses ranging from 1 week (COMPAQH) to 1 year (CIST Scotland) may indicate different definitions for data collection and reporting periods, different approaches as to the scope of data collection and analysis as well as different procedures and technological solutions to facilitate reporting, such as using computerized procedure for the production of hospital performance reports. One project also performs a so-called ‘structural dialogue’ (BQS). It can be described as a hearing request from the users linked to a feedback loop provided by the indicator projects in order to identify statistical outliers, interpret performance and identify quality improvement actions. The structural dialogue differs from a workshop because the main purpose is to identify possible problems and quality improvement activities with regard to each indicator, while the main purpose of the before mentioned workshops is to educate the users to understand how to collect and interpret data.
With regard to the project's budget, we were only able to obtain the budget for QIP and ACHS through publicly available documents. For other projects, we obtained information directly from the project coordinators. Furthermore, only four projects (QIP, COMPAQH, NIP and the Dutch projects on reporting of performance in hospitals) could inform us of the exact budget. The budget for the longer established projects may indicate the administrative, methodological and technological requirements for the successful and efficient operation of a quality indicator project.
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Discussion |
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This paper has briefly explored 11 indicator projects to assess performance in hospitals. Based on the available public documents and websites, 10 criteria of the projects were determined. Our inductive approach to developing criteria does have its limitations as it is based on publicly available information on performance indicator projects and articles published on performance assessment projects, and we might have overlooked some valuable information addressing other criteria. Furthermore, it can be criticized that we involved only well-established indicator projects in the assessment and that we neglected smaller initiatives that are side projects of other quality assessment or improvement projects and cannot be characterized as performance assessment projects. However, the strength of our approach is that each project coordinator validated the use of the criteria, the information gathered from publications and web pages as well as the information extracted from interviews. We believe that this validation process adds substantially to the paper as the comparability of published information alone may be limited due to the lack of consensus on definitions and concepts.
The review showed that the projects differ quite significantly according to some of the criteria. In particular, there are substantial differences in the underlying philosophy of the projects as characterized, for example, by a policy towards disclosure of the results to the public vs. restricted use of data for internal quality improvement. It is further difficult to describe the focus of the projects as the performance dimensions are defined in a heterogeneous way.
Development and reporting of indicators
The procedures for developing indicators appear to be similar. As mentioned in the results, all projects used expert groups and user groups in the phase of developing and selecting indicators, which indicates a combination of top-down and bottom-up approach; however, we were not able to retrieve further information on the assessment of the specific properties of each indicator in the various projects, such as an assessment of reliability, validity, sensitivity and specificity. The comparison indicates that the involvement of patients and citizens in developing indicators is more common in public-disclosure initiatives.
The most common measurement areas include, not surprisingly, clinical effectiveness, patient centeredness and patient safety. Considering the decreasing length of stay in hospitals worldwide and the fact that patient-relevant outcomes can only be measured in a longer time perspective, hospital performance assessment initiatives may in the future be confronted with major methodological challenges and the need to broaden assessment domains. Some initiatives (PATH, OHA and Verein Outcome) already address the responsive governance domain, and it can be expected that in the future a stronger focus will be expected by financers and users to address longer-term and sector-wide performance assessments.
In terms of reporting data, some projects provide results only to hospitals, whereas others also inform the public. In our results appears a strong association between ‘participation’ and ‘public disclosure’, e.g. all the projects that are based on non-voluntary participation disclose the results to the public, except the Bundesgeschäftsstelle Qualitätssicherung (BQS) in Germany. Projects that are based on voluntary participation stress that the use of performance data is for internal purposes only.
Public disclosure of performance, defined as an opportunity for the consumer (patient), to demand information on the quality of healthcare (clinical effectiveness, hygiene, health care etc.) in hospitals, is a controversial issue. Recent research indicates that patients do make use of such information to choose providers, and public disclosure can thus be seen as a motivational factor for the hospitals to work and invest in better performance assessment systems [25]. However, other studies report that consumers judge information on quality as more trustworthy and easier to understand if they obtain it from family and friends or from their own past experiences [26, 27]. There appears to be a risk therefore that consumers may not be able to interpret the information generated by hospital performance assessment projects and their more intense involvement is warranted to ensure appropriate design of feedback mechanisms.
Competition
We are aware of co-existing indicator projects at local/regional, national and international level [3]. For example, in Germany, where all hospitals are obliged to participate in the BQS project some hospitals also participate on a voluntary basis in the International Quality Indicator Project (iQIP) (www.internationalqip.com) and in PATH. This may reflect that some hospitals are interested in participating in more projects and comparing additional performance data at cross-national level. However, it also entails the risks of duplication of strategies. With the development of indicator projects all over Europe, such a risk needs to be addressed in particular if existing projects collect similar indicators with slightly different definitions, which could result in a high burden of data collection and could impact negatively on the motivation of health professionals to participate and contribute to such projects. To meet this challenge, a mapping exercise could be carried out on the type, scope and actual definitions of indicators used in different projects, which, given the number of indicators used by the different initiatives, is beyond the scope of this paper. In addition, further research should address resources required for data collection, in particular, since new projects use routine data for performance assessment and quality improvement in an attempt to reduce the amount of time withdrawn from clinical activities [28, 29].
PATH compared with the national projects
PATH as a tool for quality improvement in hospitals based on voluntary participation shares approaches and strategies with other projects based on voluntary participation. As PATH is both a flexible and a comprehensive framework, it can be applied to different national contexts and is of particular use in countries where no indicator projects exists or where existing projects narrowly focus on selected dimensions of hospital performance assessment [10]. To our knowledge, only one other hospital performance assessment project operates at international level, the IQIP. While IQIPs strength lies in the robustness of its procedures and the scientific approach in the use of indicators, an advantage of PATH is its multidimensional framework for comprehensive performance assessment. The early development phase of PATH as compared to the other projects both entails advantages and disadvantages. As a project in development, PATH is very sensitive to feedback from users and can easily incorporate suggestions from the field in new procedures for data reporting and analysis. A disadvantage of PATH though is that the resources for the coordination of services, research and development are very limited and WHO needs to take a strategic decision on the positioning of the project in the future. Furthermore, considering the differences in hospital information systems throughout Europe, major efforts need to be made to ensure the comparability of data. It also needs to be ensured that the indicator sets reflect measurement areas that are of relevance to a broad range of facilities. However, given the current shortage of hospital performance assessment initiatives in Central and Eastern European countries and considering the movement of patients across European borders (and hence the need to assess the quality of cross-border care), there are many opportunities for developing PATH.
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Conclusions |
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TopAbstractIntroductionMethodologyResultsDiscussionConclusionsAcknowledgementsReferences |
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The purpose of this paper was to provide a review of 10 current national indicator projects that are measuring hospital quality and compare them with the WHO PATH project. The review identified many similarities in hospital performance assessment projects, such as the use and scope of indicators; however, we also identified fundamental differences in the philosophy of the projects, which should be addressed by further research. Given the conceptual differences in the design, and the overlap of some projects, it would be useful to assess the comparative effect and costs of different indicator projects. Furthermore, many projects are based on a set of assumptions (e.g. that information systems get better, that clinicians use the data to discuss results, that patients use the performance report to select care provider) and we found little information on a systematic evaluation of these assumptions in relation to the projects identified. Finally, for international projects such as PATH, it will be essential to coordinate with national authorities in order to avoid overlaps in indicators definitions. Mapping exercises could be carried out to avoid that similar areas of interest are covered by slightly different indicator definitions.
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We acknowledge the insightful comments of Dr. Paul Bartels, Director of the Unit of Clinical quality and patient safety and the National Indicator Project, Denmark and Dr. Eileen Spencer, Researcher in the Method Assessing Response Quality Improvement Strategies project and Researcher at the University of Manchester. We also thank the representatives of the contacted projects for their contributions to validating the information and providing helpful comments during interviews:
Mrs. Christine Farraway, Team Leader—Performance and Outcome Service, Australian Council on Health care and Standards; Mrs. Joanne Maharaj, Project Assistant—Hospital Report & Patient Satisfaction, Ontario Hospital Association, Canada; Dr. Margaret McLeod, Quality Improvement Programme Manager and Dr. Donald Morrison from National Health Service Quality Improvement in Scotland; Dr. Christine Coudert, Head of the project COordination pour la Mesure de la Performance et 
Amélioration de la Qualité Hospitalière (COMPAQH); Mr Burkhard Fischer, Bundesgeschäftsstelle Qualitätssicherung (BQS); Sharon Sprenger, Project Director—Group on Core Performance Measurement and Nancy Lawler Associate Project Director, Joint Commission Accreditation of Health Organisations; Professor Vahe Kazandjian, President Center for Performance Sciences, Quality Indicator Project; Mr. Dirk Wiedenhöfer, Verein Outcome; Professor Gert Westert (National Institute for Public Health and the Environment and Tilburg University) and Mr. Jan Haeck MD, Senior Inspector from the The Netherlands Health Care Inspectorate (IGZ), The Netherlands.
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