How can hospital performance be measured and monitored?

Summary

The issue

Measurement is central to the concept of quality improvement; it provides a means to define what hospitals actually do, and to compare that with the original targets in order to identify opportunities for improvement.

Findings

The principal methods of measuring hospital performance are regulatory inspection, public satisfaction surveys, third-party assessment, and statistical indicators, most of which have never been tested rigorously. Evidence of their relative effectiveness comes mostly from descriptive studies rather than from controlled trials. The effectiveness of measurement strategies depends on many variables including their purpose, the national culture, how they are applied and how the results are used.

Inspection of hospitals measures minimal requirements for the safety of patients and personnel; it does not foster innovation or information for consumers or providers.

Surveys usually address what is valued by patients and the general public. Standardized surveys measure specific domains of patient experience and satisfaction. There are also standardized surveys that reliably measure hospital performance against explicit standards at a national level.

Third party assessments may include measurement by standards, by peer review or by accreditation programmes. ISO standards assess compliance with international standards for quality systems, rather than hospital functions per se. Peer review is generally supported by clinical professions as a means of self-regulation and improvement, and does not aim to measure the overall performance of hospitals. Accreditation programmes are managed by independent agencies in several countries. They focus on what may be improved rather than on failures, and are oriented toward the patient, the clinical procedures, outcome and organizational performance. These programmes require substantial investments, and there is ample evidence that hospitals rapidly increase compliance with published standards and improve organizational processes in the months prior to external assessment. There is less evidence that this brings benefits in terms of clinical process and patient outcome.

Statistical indicators can suggest issues for performance management, quality improvement and further scrutiny; however, they need to be interpreted with caution. Much of the current evidence on the effectiveness of performance indicators is based on observational or experimental data. Some experience suggests that indicators such as guidelines to standardize management of common conditions may reduce length of stay and episode costs without detriment to clinical outcome. The publication of performance statistics as “league tables” aims to encourage improvement, to empower patient choice and to demonstrate a commitment to transparency. Evidence suggests that this increases public interest and management attention to data quality, but it does not appear to have much effect on performance.

Policy considerations 

Systems for measuring hospital performance should be published in a national or regional plan for quality and performance management, and clarify the roles and values of stakeholders.

The design of performance measurement systems should aim to improve hospital performance, rather than to identify individual failures. Systems should not rely on single sources of data but should use a range of information. Consumers should be prominently involved, and the results of assessments should be transparent and freely accessible to the public.