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Measuring Performance

If there is anything that characterises the early 21st century, it is the push to measure everything.  Even the pleasure of a well-coached win for your footy team (apologies to NRL fans) or the soaring mark is reduced to a table of statistics in Monday’s paper.

16 Jul 2011

By Professor Geoffrey Dobb

If there is anything that characterises the early 21st century, it is the push to measure everything.  Even the pleasure of a well-coached win for your footy team (apologies to NRL fans) or the soaring mark is reduced to a table of statistics in Monday’s paper.

So it is in health, and many medical specialties now contribute to registries that enable comparison of individuals, department or hospital performance against peer benchmarks.  Other performance benchmarks include the key performance indicators of the Australian Council for Health Care Standards (see www.achs.org.au/cireports/), the information available to members of the Health Roundtable and the reports from the Australian Institute of Health and Welfare.

Both a Performance Authority and an independent Pricing Authority made some sense when the Commonwealth was going to fund 60 per cent of the efficient price of public hospital health services – whatever that might be.

With the rollback of the Rudd agenda, the Commonwealth commitment to public health funding is now much less - just 45 per cent of the increase in cost by 2014, and 50 per cent by 2017.  What this will translate into in dollar terms is still unclear.

However, the message from this year’s Commonwealth and State budgets is out.  From the Commonwealth, an extra $750 million over four years for rural and remote hospital projects but little, if anything, in real growth funding for running costs.  In contrast, State budgets have provided up to over eight per cent more funding for public hospitals in 2011/2012, but with considerable variation in expenditure growth between jurisdictions.

Against this background, it is hardly surprising that Health Ministers, commentators and many in health care have questioned the need for a centralised Performance Authority to be run out of the Commonwealth bureaucracy with all the overheads that implies.  The recent meeting of Health Ministers appears to have changed the balance between the Commonwealth and States on the manner of reporting.  But concerns about independence from Government - Commonwealth or State - remain, as does the potential for wasteful duplication of reporting requirements.  

The AMA supports comprehensive, robust and transparent reporting of public hospital performance against nationally consistent standards.  What seems to be missing from the process for developing a Performance Authority or, better, an independent reporting body, is meaningful clinical consultation and involvement in developing a reporting framework.

If there had been such consultation, outsourcing to organisations such as the ACHS or AIHW through a tender may have been considered more actively.  It is also probable that greater detail would be available on the methods for standardising data collection, agreeing on definitions and a data dictionary, adjustment for confounding factors, data monitoring and audit, and the process to be used to identify performance outliers.   This would need to be coupled to the means to identify the causes of relatively poor performance and the resources to get back on track.

A comprehensive Performance Authority or similar agency would also monitor the proportions of public hospital funding from the Commonwealth and States over time, and the Commonwealth’s performance in the closely related aged care sector.

Clinicians have concerns about crude performance reporting without context or adjustment for confounding factors.

While it can be argued that Australia has lagged behind other countries in the public reporting of outcomes from episodes of hospital care, recent publications suggest that crude global measures such as the hospital standardised mortality ratio need considerable refinement before they should be used as a measure of hospital ‘quality’.

We can also learn from the problems with the reporting of performance measures for schools. 

If performance reporting is going to happen, let it be the most robust, cost effective system that can be devised – and that will need extensive clinical input.

Performance reporting can drive change in our health system, but the wrong measures risk driving it in perverse directions.


Published: 16 Jul 2011