Traditional expectations about healthcare continue to be challenged by the umbrella concerns about accountability and trust. The core of this challenge is two-fold: healthcare providers have seen the absolute trust placed into their intentions and practices erode through the quantification of quality and safety of care, and, the recipients of care have been empowered with timely and specific data to demand accountability rather than unquestionably trust providers. The purpose of this chapter is to review the key dimensions of the operationalization of performance measurement and the translation of its findings to statements about quality and safety of care. The past four decades have seen the continuous discovery and refining of analytical tools to quantify what once was taken for granted: that patients always receive the best care possible. These tools have uncovered the probabilistic nature of medicine and the resulting nature of the relationships outcomes have to processes. Hence the expectations of patients, payers of care and policy makers require being continuously modified to reflect the limitations of medicine and healthcare. The education of various audiences as to what the measures mean not only is a necessary requisite for sound project design but also will determine how the accountability model is shaped in each environment based on the generic measurement tools results, local traditions of care and caring, and expectations about outcomes.
TopIntroduction
There is, as it should be, ongoing debate in health services research about the best tools for measuring health care performance. Yet, and in parallel with the search for the best tools, external requirements for data reporting and accountability about quality and safety of care are shaping the focus of inquiry, the nature of the measurement strategies, and the models of accountability. The central themes for the debate could be summarized under the following categories:
- •
The focus of the inquiry;
- •
The adoption of state of the art measurement science; and,
- •
The promises about how the healthcare system would increase appropriateness, enhance its safety, and demonstrate these changes in a systematic and ongoing way;
- •
The communication with and education of those responsible for policy.
This chapter addresses the topic of quality through the measurement of performance specifically in hospitals. It is not the purpose of this chapter to review performance measurement systems, but to discuss the above three categories as fundamental to all performance measurement and evaluation systems. As an illustration, voluntary data reporting about medication safety is discussed addressing the three themes of this paper: focus of inquiry, measurement, and the promises for increasingly appropriate and safe health care services.
TopThe Focus Of The Inquiry
“Where to look?” is the first question during an inquiry, and one would assume that there is sufficient and progressive guidance to professionals to initiate this inquiry. Unfortunately, that is not the case. “Traditional” aspects of care and caring have been evaluated ad nauseam in the past fourty years with variable outcomes. The focus on the area of inquiry not only varies by the health care system's traditional beliefs on how services should be delivered (Cylus et al, 2015; Ladhani, et al., 2014; Hyppönen, et al., 2014; Moses, et al., 2103; Merlino & Raman, 2013), but also by the expectations of the recipients of care (Health Affairs, 2016; Danforth et al, 2013; Carvalho, 2013; Marcieca et al, 2013). The introduction of recipient expectations regarding access to quality care, empathy by the caregivers, and affordability of the services is a relatively new paradigm even in health care systems with a tradition of accountability. The novelty of the paradigm is in its departure from the purely “professional model” (Jha et al, 2014; Parchman & Burge, 2004; Firth-Cozens et al, 2004; Snyderman & Williams, 2003; Redman & Lynn, 2004) where expectations are defined à priori by those who deliver the care and caring. The dissonance between the professionals’ opinions about appropriateness and the recipients’ expectations of good outcomes becomes apparent when performance measurement systems are also used towards accountability (Kazandjian, 2002; Kazandjian et al, 2005). Challenging the professional model of beliefs is a departure from the central concept of trust inherent in a few true professions. Perhaps the most apparent parallel in challenging the concept of trust is one between the profession of medicine and that of clergy (Kazandjian, 1999). Indeed, if a profession is based on peer-review, such as medicine and clergy, than the exclusive ownership of the knowledge they own and keep are for the well-being of the people they serve and therefore of late, clergy and medicine have been challenged to demonstrate accountability through quantitative, periodic, and measured demonstration of how their social mission is being accomplished. This request by communities is a significant departure from the traditional relationship of “don't ask, just trust” whereby the outcomes of services provided were not directly linked to the belief in the appropriateness of the process. This is of significant importance as quantification of performance naturally links processes to outcomes and eliminates all subjective feelings of trust that cannot be substantiated. In other words, the concept of trust is built on the belief that, in all situations, the professional will be providing the most appropriate service to those in need of those services. And that such an appropriate service would be delivered in the most adequate and efficient way within the context of knowledge and resources. Therefore, within the context of trust, it is the process that matters not the outcome.