Quality in Health

PROMOTING QUALITY IN HEALTHCARE: PERFORMANCE MANAGEMENT

Umesh Gupta*, Anupam Sibal**and Anupama Sharma#

From the: Quality Head & Decision Support Services, Consultant Vascular Surgeon*, Director Medical Services & SeniorConsultant, Pediatric Gastroenterologist**, ICE team Member & Service Line Leader Gastroenterology and Transplant#.,

Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India.Correspondence to: Dr. Umesh Gupta, Quality Head & Decision Support Services, Consultant Vascular Surgeon,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India.

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INTRODUCTION

QUALITY is the big issue, which is currently fashionable inhealthcare circles in several industrialized countries. Quality isa desired entity by all healthcare providers. As ethicalconsiderations, it is the fabric of the very existence ofhealthcare professionals. Joint Commission on Accreditationof Healthcare Organizations (JACHO) has been developingquality metrics. There has been an explosion in thedevelopment of performance indicators of variableprovenance and quality. Developing, collecting, analyzing,and feeding back performance data from healthcareorganizations is now big commerce.

There is a danger that that efforts made in assessingperformance (measuring aspects of health improvement, fairaccess, effective delivery of appropriate care, efficiency, thepatient experience, and health outcomes) will not result in theanticipated gains in quality because of potential conceptual andtechnical weaknesses in the performance management agenda.The tone is cautionary in the context of the rapid investment inand relatively unevaluated adoption of performance indicatorsas one of the key elements of quality improvement strategies,whether the approach used is one or more of regulation,competition, continuous quality improvement, or financialincentives. [1,2].

COST EFFECTIVENESS AND QUALITY

Quality is now given such prominence on the health policyagenda is surely a good thing, but unless it is defined andsensibly used, calls for quality improvement will becomemerely slogans or fashion statements. This is not an easy task.Quality requires efficiency in the use of healthcare resourcesand effectiveness in delivery of care and service.

Cost effectiveness must lie at the heart of quality. In thecurrent era of cost constraints and limited resources evenhealthcare institutions must demonstrate their ability toprovide services most effectively and efficiently. It is a matterof survival in today's volatile market. This involves bothallocative efficiency investing in the types of interventionswhich produce the most benefits (valued by consumers)-andtechnical efficiency-applying these interventions in the mosttechnically competent and least wasteful fashion. Under this

broad concept of quality, care would have to be clinicallyeffective and medically appropriate, clinicians would need tobe competent, and errors minimized and the systems fordelivering care run smoothly and efficiently. For example, noone would suggest devoting all the resources to preventing justone more medical accident or to providing one more hipreplacement. Non-quality causes problems and problems costmoney. Costs are then wasted to detect those problems(appraisal costs) in order to prevent those problems (failurecost). Very few quality improvement schemes either look at theefficiency of the strategy or include cost effectiveness as part ofquality or performance indicators just as few clinical practiceguidelines integrate evidence on resource use [3].

PERFORMANCE MANAGEMENT

The issue of a performance management framework can beconsidered at two levels: conceptual and technical. Attention isoften focused overly on the technical characteristics ofindividual measures rather than the conceptual approach.Performance management uses regulatory initiatives bygovernment or purchasers to penetrate organizations, tochange or reorder internal activities and relations and ensurescompliance with rules while at the same time having less directcontrol or management responsibility for the running ofservices. All indicators embody a system of values and socialgoals. By affixing the right labels to activities it is possible toturn them into desirable or valuable services, which mobilizethe commitment of internal participants. Different indicatorsproduced by different organizations or processes will reflectdifferent values. In other words performance indicators are notsimply technical entities but they have programmatic ornormative elements, which relate to the ideas and concepts,which shape the mission of practice.

The potential impact of applying a set of indicators dependsnot only on their technical characteristics but also on the degreeto which those managing, working in, and using healthcareorganizations support the programme, the existingprofessional cultures, and what change in the culture theintroduction of performance management may produce. Forexample, when performance measurement frameworks areapplied to organizations, they may tend to displace or replacepre-existing formal and informal internal or professional

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Quality in Health

THE LAW OF UNINTENDED CONSEQUENCES

Focusing too heavily on a few indicators, other aspects ofthe service, which are not being measured or are not someasurable, may get less attention. Thus while the measuredperformance may improve, quality may fall in the lessscrutinized areas, resulting possibly in a fall in overallperformance. Depending on the indicators used, this may alsoengender a short-term culture. Action to ensure goodperformance on this year's indicator may replace morestrategic thinking about how to make more fundamental long-term improvements.

When indicators measure change over time-for example,as percentage change-organizations may purposefullyunderachieve in one year to be able to show steadyimprovement over time, and organizations at a high level tostart with may look worse.

It is difficult to develop indicators which measure aspectsof clinical effectiveness because the clinical decision makingprocess is complex and takes into account factors that are notvisible at the macro level. The inability of indicators to lookinside the clinical process can result in a misinterpretation ofthe results. Similarly, indicators of access that measure rates ofeffective surgical operations-such as CABGs, and hip and kneeoperations-are difficult to interpret because their effectivenessdepends on who is receiving them [5].

WHEN TO USE PERFORMANCE INDICATORS?

Researchers are often criticized for being overly cautious.However, in this situation, given the resources that will be usedand the potential negative effects of the introduction ofperformance indicators, caution is an appropriate response. inwhich quality can be improved and the role within this forperformance indicators.

Certain lessons can be learned from the internationalexperience. Firstly, any system for measuring and improvingperformance should be integrated or coordinated with otherparts of the service that are trying to promote quality. Forexample, where possible, indicators should be developedalongside the production of evidence-based clinical practiceguidelines or guidance to which people are signed up to at alocal or national ultimately though we need high qualityexperimental evaluations of quality management initiativesalongside a better conceptual understanding of how to evaluateorganizational performance [6].

CONCLUSION

Any performance management system should beintegrated with other quality initiatives to promotecoordination. A blend of scientific accuracy, relevance tovalues, goals, and policies of the political community and ofhealthcare professionals is needed. Any health serviceembarking on performance management should attempt toestablish whether it will produce the desired effects and at what

modes of quality assurance. What we rarely ask ourselves iswhy there are not more poor outcomes; what are professionalsalready doing, what strategies do they currently use whichresult in good outcomes, how do they successfully avoid errors,and how could we build on these to help make health care evenbetter?

Auditing of performance-such as clinical effectiveness-bythe use of externally imposed indicators may havedysfunctional side effects. The key question is whether anypotentially positive effect of these externally applied indicatorswill be counterbalanced by the negative effect of dismantlingother mechanisms of quality assurance? Performancemeasurement and reporting, inappropriately used, can createan environment of fear instead of fostering qualityimprovement. Measurement alone does not improve quality,and indeed, when seen primarily as a way to improveaccountability and to make judgments, may be self defeating,reducing morale, and causing the collapse of other qualityenhancing activities not part of the performance managementstrategy. "Measuring for improvement is not measuring forjudgment"-measurement is more likely to be an Asset whenconnected to curiosity and learning [4].

PROBLEMS OF USING PERFORMANCEINDICATORS

Much has been written about the potential problems ofusing performance measures and this literature alerts us to theconsiderable risk that some performance managementstrategies may not be as effective as anticipated. As well as theconceptual issues already raised, there are two main problems:“decoupling” where the measures are rendered ineffective and“colonization” where they are effective in unintended ways.For example, adverse anesthesia events are being documentedworldwide by healthcare organizations as an indicator foranesthesia and an international protocol for grading areused for the same, but here we observed the recordedevents over a period of time were close to zero. After given athought and discussion with anesthesiologists indicator wasmodified to recovery room delays which in turn revealedaspects related to pain management where post-Op pain wasfound to be the major contributing factor in recovery roomdelays.

Variations in performance can be particularly difficult tointerpret unless there is also adequate adjustment for case mix.Case mix adjustments would help to explain the variationbetween the rates observed in a community. Interpretation ofthe results is challenging when health outcome data are usedbecause these are affected by so many variables, most of whichare not directly under the control of the health service.Although it may be important to measure these variables to seewhere there are unwanted changes or lack of improvement,they cannot be attributed easily to any particular part of thehealth service or health service activity, and so cannot beregarded as valid or sensible measures of health serviceperformance.

Quality in Health

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cost before it is fully implemented. This is particularlyimportant given the deep cynicism between the healthcareworkforce and many managers about the value of performancemeasures.

REFERENCES

1. The Department of Health. The new NHS modern anddependable. London: DOH, 1997. (available on: http://www.open.gov.uk)

2. Thompson RG, McElroy H, Kazandjian VA. MarylandHospital Quality Indicator Project in the United Kingdom:an approach for promoting continuous quality improve-ment. Quality in Health Care 1997; 6: 49-55.

3. The Department of Health. A first class service: quality inthe new NHS. London: DOH, 1998. (available on: http://www.open.gov.uk)

4. Kazandjian VA, Lied TR. Caesarian section rates: effectsof participation in a performance measurement project.Journal of Quality Improvement 1998; 24: 187-196

5. Ballard DJ, Cangialose CB. Eight recommendation formaximising the return on investment in external qualityoversight. Int J Qual Health Care 1997; 9: 83-86.

6. Sicotte C, Champagne F, Contandriopolous AP, et al. Aconceptual framework for the analysis of health careorganizations' performance. Health Services Manage-ment Research 1988; 11: 24-40.