Jean-Frederic LevesqueChief Executive

Using Clinical Outcome Data to Improve Patient Care

3 June 2014NSW State Office CPD Event

The Royal Australasian College of Physicians

Outline of the presentation

• Why measure and report on performance?

• Accountability and quality improvement

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

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

Why measure and reporton performance?

National Health Performance Authority

Canadian Institute of Health InformationUK Care Quality Commission

USA Institute for Health Improvement

Ontario Quality Council

La haute autorité de santé FranceUSA Accountable Care Organisation

Quebec’s Health and Welfare CommissionerBureau of Heath Information

“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

“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

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.

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

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)

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

Insights into Care

Aim: explores information about specific topics in patient care and identifies opportunities to improve the healthcare system

Patient Perspectives

Aim: provides information about what patients are saying about their healthcare experiences

What is performance really?

Quality of Care

Patients participation and engagementEfficiency and value for money

Adverse events and complications

Staff morale and stability

Respectfulness and dignityContinuity of care and coordination

Conformity to clinical guidelinesPerformance of healthcare

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.

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.

An integrated model of performance measurement

Clinically-relevant dimensions of performance

• Productivity

• Accessibility

• Appropriateness

• Effectiveness

Productivity : being organised, doing more

Productivity : being organised, doing more

Measurements of primary care volumes of services per resources invested: human and financial resources

Maximising ambulance transportation

Accessibility: healthcare where and when needed

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

Appropriateness: The right healthcare, the right way

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

Appropriateness – technically proficientMedical Errors  In the past two years, have you experienced?

Appropriateness – patients’ experience of care

Effectiveness: making a difference for patients

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

Hospitals with higher than expected results

30-Day Mortality: Mortality in hospital following discharge

Hospital profile: Dashboard

Hospital profile: in context

Policy-relevant dimensions of performance

• Efficiency

• Equity

• Sustainability

• Impact

Whose performance is it anyway?

Dashboards

Clinical and provider assessmentsAnonymised reports

Balanced scorecard

Audit and clinical competency

System and organisational perspectivesKey performance indicators and targets

Ranking of hospital facilitiesReporting on performance

Some challenges of attribution

• Performance is a nested process, enacted at the levels providers, organisational and system levels simultaneously

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

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

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

Enhancing attribution potential

• Relating measures of needs, resources, processes and outcomes to derive true constructs of performance

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

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

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

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