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EHMA Annual Conference, Athens, Greece

Katrien Verleye

25 – 27 June 2008

INCREASING IMPORTANCE OF PERFORMANCE MEASURES IN THE HOSPITAL SECTOR

Equity under pressure?

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Overview

1. Context

2. Research questions

3. Methodology

4. Results

5. Discussion

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CONTEXT

HOSPITAL’S PERFORMANCE

REGULATORS AND

OTHER ENTITIES

Suppliers

Consumers and purchasers

Internal members

Kanji & Sá (2003)

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CONTEXT

Need to control costs without losing qualitycf. increasing costs and need in budget

Increased attention for quality improvementcf. lapses in quality

Focus on controlling the financial performance

Ensuring quality as important issue in hospital sector

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CONTEXT

Demand for transparency and accountability

PERFORMANCE MEASUREMENT (PM)…

» … translates the hospital’s performance in quantifiable metrics

» … informs different stakeholders on the hospital’s performance

» … enables stakeholders to follow up, coordinate, control and improve (aspects of) the hospital’s performance

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RESEARCH QUESTIONS

performance

development

selection

measurement interpretation management

1. How is performance defined?

2. How is performance measured within the hospital sector?

3. How is performance information used within the hospital sector?

4. How do hospitals evaluate their performance measurement systems?

5. Which are the implications of PM on equity in healthcare?

PERFORMANCE MEASUREMENT MODEL

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METHODOLOGY

Evaluation of PM in hospitals in Belgium

FLEMISH CASE

- subjected to the Belgian government Cf. http://www.belgium.be/en/health/index.jsp

- subjected to the Flemish governmentCf. http://www.zorg-en-gezondheid.be/HomeEN.aspx?id=1182

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METHODOLOGY

Flemish Region Flemish Communtiy Population: 6,117,440

Total area: 13,522 km²

5 Flemish Provinces

Acute hospitals:

• 62 hospitals

• 104 campuses

Universitary hospitals:

• 4 hospitals

• 6 campuses

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METHODOLOGY

Survey in 13 Flemish hospitals

- 2 to 3 hospitals per Flemish province

- both universitary and non-universitary

- interpretation of each PM step

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RESULTS

*PERFORMANCE

- multidimensional

- influenced by stakeholders

- context

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RESULTS

SELECTION AND DEVELOPMENT OF PIs

- measuring all performance aspects: unfeasible and irrelevant

- several performance aspects and indicators

- motivation • statutory required !!!• supportive networks• self-developed indicators: result of historical factors

added value for hospital

**

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Statutary required financial indicators Statutary required minimal hospital data Clinical indicators Navigator Patient safety indicators Navigator Operational indicators Navigator Patient satisfaction indicators Employee satisfaction indicators HR indicators Financial indicators Clinical indicators VZN Leuven Clinical indicators Patient safety indicators Complaint services Clinical indicators PATH-2 HR indicators PATH-2 Logistic indicators

RESULTS

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RESULTS

BUT

- too many PI’s and unclear definitions

- “not reflecting the performance”

- “difficult to find reliable and valid indicators”

- no participation of employees in the selection

**

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RESULTS

PERFORMANCE MEASUREMENT

- measurement on the departmental level

- several employees are involved

- mostly supported by ICT

*

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RESULTS

BUT

- lack of motivation

- time consuming

- incorrect and incomplete data

- overlap

*

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RESULTS

ANALYSIS AND INTERPRETATION

- focus on deviating measures

- supported by ICT: basic analysis

- put out the data analysis to supportive network• Government• Navigator• Flemish Hospital Network Leuven

*

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RESULTS

BUT

- feedback government and supportive networks not satisfactory

- no integration of performance indicators

- lack of standards

*

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RESULTS

USING PERFORMANCE INFORMATION

“what gets measured, gets done”= ‘the most famous aphorism of performance measurement’ (Behn, 2003)

VERSUS

“to raise questions, not to provide answers”(Likierman, 1993)

*

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RESULTS

USING PERFORMANCE INFORMATION

*Heemskerk & van Zandwijk (2004)

Kanji & Sá (2003) FLEMISH HOSPITALS

(external) justification

communication to employees

communication and reporting

giving accountgiving account

(internal) direction examining progressstrategic planning &

implementation

driving improvementimproving

performance

supervisionresource allocation

decisionsdecision-making

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RESULTS

BUT

- employees are not informed

- external use, but limited internal usecf. ‘information is too general to use’cf. ‘PM is not embedded in the decision structure of the organization’

- PM does not achieve its goal

*

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DISCUSSION

FOCUS ON USING PERFORMANCE INFORMATION

1. Comparison among hospitals

2. Having decisions made by external stakeholdersCf. accreditation

Cf. pay-for-performance

3. Public disclosure of performance information Cf. rankings

Improving the performance of hospitals(Chandrima, 2005; Hamblin, 2007; Helm, Holladay & Tortella, 2007)

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DISCUSSION

COMPARISON AMONG HOSPITALS

- incomplete and incorrect measures- different ways of measuring indicators- different indicators

- different definitions

- based on different strategies

- different input !

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DISCUSSION

DECISION-MAKING BY EXTERNAL STAKEHOLDERS AND PUBLIC DISCLOSURE

- reflecting performance?cf. tunnel vision (Vakkuri & Melkin, 2006)

- is standardization possible?cf. differences between hospitalscf. do hospitals have a sector-specific strategy?

- getting a good score in stead of improving performance cf. risk of misrepresentation (Vakkuri & Melkin, 2006)

• specializing in a few domains• refusing patients who lower score

- risk of ossification (Vakkuri & Melkin, 2006)

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DISCUSSION

CAUTION IS RECOMMENDED

revising previous steps before use- reflection- systematization

adjustment for patients’ characteristics

performance measures are “flags requiring cautious interpretation in the light of local circumstances” (Veillard et al., 2005; p. 492)

involvement of different stakeholders

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Interesting references

Behn, R.D. (2003). Why measure performance? Different purposes require different measures. Public Administration Review, 63( 5), 586-606. Aidemark, L.-G. (2001). The meaning of balanced scorecards in the health care organisation. Financial Accountability & Management, 17(1), 23-40.

Bauer, K. (2004). KPIs – the metrics that drive performance management. DM Review, 14(9), 63-64.

Becker, B., Formisano, A., & Roger, M.D. (2006). Strategic planning for departmental divisions in an academic health care centre. The American Journal of Medicine, 199(4), 357-365.

Chandrima, B.C. (2005). Accreditation in hospitals. Expressed Healthcare Management. Retrieved May 7, 2008, from http://www.expresshealthcaremgmt.com/20050915/accreditation01.shtml.

Heemskerk, P., & Van Zandwijk, M.C. (2004). Verantwoordingsprocessen in de zorg op basis van de balanced scorecard. Zoetermeer: het Expertise Centrum.

Helm, C., Holladay, C., & Tortorella, F.R. (2002). What’s in a name? Reporting data from public institutions. CMAJ, 22(2), 193-194.

Kanji, G.K., & Sá, P.M. (2003). Sustaining healthcare excellence through performance measurement. Total quality management, 14(3), 269-289.

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Interesting references

Kollberg, B. Elg, M., Lindmark, J. (2005). Design and implementation of a performance measurement system in Swedish health care services. Quality Management in Health Care, 14(2), 95-111.

Rooney, A.N., & van Ostenberg, P.R. (1999). Licensure, accreditation, and certification: approaches to health services quality. Center for Human Services. Retrieved May 4, 2008, from http://www.qaproject.org/pubs/PDFs/accredmon.pdf

Tarantino, D.P. (2003), Using the balanced scorecard as a performance management tool. The Physician Executive, September-October, 69-72.

Ten Asbroek, A.H.A., Arah, O.A., Geelhoed, J., Custer, T., Delnoij, D.M., & Klazinga, N.S. (2004). Developing a national performance indicator framework for the Dutch health system. International Journal for Quality in Health Care 16(1), 165-171.

Vakkuri, J., & Meklin, P. (2006). Ambiguity in performance measurement: a theoretical approach to organisational uses of performance measurement. Financial Accountability & Management, 22(3), 235-250.

Veillard, J., Champagne, F., Klazinga, N., Kazandjian, V., Arah, O.A., & Guisset, A.I. (2005). A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. International Journal for Quality in Health Care, 17(6),487-496.

Yap, C., Siu, E., Baker, G.R., Brown, A.D., & Lowi-Young, M.P. (2005). A comparison of systemwide and hospital-specific performance measurement tools. Journal of Healthcare Management, 50(4), 251-264.

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Contact information

Katrien Verleye

Scientific Staff Member

+ 32 9 210 98 30katrien.verleye@vlerick.be

Reep 1B-9000 GentBelgium

www.vlerick.com

Vlerick Leuven Gent Management School