Quarterly Letters: Assessing Hospital Performance
I read with interest two articles in Hospital Quarterly, Winter 1998/99; "Healthcare Performance Measurement in Canada: Who's Doing What?" and "What Does the Public Want to Know about Hospital Performance?" Both stress the importance of the public release of indicators of hospital performance and accountability in healthcare. Baker and his colleagues highlight the Ontario Hospital Association/University of Toronto hospital report card and Murray and his colleagues summarize the Toronto Academic Health Science Council Performance 98, a report card for eight teaching hospitals. The articles are fine as far as they go, but neither covers the history and context of assessing hospital performance, particularly in Ontario.
In 1991, the Ontario Ministry of Health publicly released the report of the Cesarean Birth Planning Committee, chaired by Dr. Karyn Kaufman, Appropriate Use of Cesarean Section, Recommendations for a Quality Assurance Program. It presented the cesarean sections rates for each Ontario hospital for 1988/89. As I understand it, this was the first time the government released a report card on hospital performance. In the winter of 1992, the Vaginal Birth After Cesarean/Accouchement Vaginal Apres Cesariene Canada published the same data for 1989/90 in The VBAC/AVAC Canada Newsletter. The VBAC/AVAC became the first consumer group to report the performance of hospitals in Ontario.
As soon as it was inaugurated, the Institute for Clinical Evaluative Sciences (ICES) began defining key indicators of hospital performance in Ontario, based on available administrative data. Hospital specific reports have been subsequently released in ICES Practice Atlases in 1994 and 1996. Other atlases and reports have focused on hospital services for cancer surgery, and cardiovascular diseases, and we have recently updated the reports on cesarean section rates. By linking hospital data with medical services from the Ontario Health Insurance Plan, claims from the Ontario Drug Benefit Program, home care service reports, and vital statistics, we have been increasingly able to relate hospital services to the subsequent use of health services and outcomes.
I should note some other contributors to the movement towards greater transparency as regards to hospital-level performance measures. In the period leading to the restructuring of hospitals, District Health Councils worked extensively with hospital performance indicators in making recommendations about reorganization. They made public the information and held hearings on the recommendations. The Health Services Restructuring Commission (HSRC) had the responsibility of reviewing the recommendations, assessing the performances of hospitals, setting forth the master plan for restructuring, and implementing it. The HSRC reports contained extensive information about hospitals' case mix, throughput, and market share, and they are in the public domain.
The Cardiac Care Network (CCN) created an information system for coronary artery bypass surgery services in Ontario. CCN gives participating centres information on performances of both hospitals and surgeons. At first the hospital indicators were released without identification, now hospital-specific data are available publicly in report cards and on the website. Waiting lists by centre have been available since 1992 and they are posted on the CCN website.
The Joint Policy and Planning Committee of the Ontario Hospital Association and the Ontario Ministry of Health uses hospital performance indicators in making recommendations about funding for hospital global budgets and specific programs of services. Utilization review managers and researchers in hospitals, district health councils, health information units, and in universities routinely use Discharge Abstract Data from the Canadian Institute for Health Information in studies of hospital performance.
The report cards by OHA/UTHA and TAHSC are important events. They added information on finances, patient satisfaction and system integration in addition to the clinical indicators of performance. I am looking forward to the OHA/UTHA report cards for individual hospitals that are to be released this fall. However it is important for all of us to be aware of the context in which the broader move to profiling hospital performance is taking place.
Stakeholders from all sectors are working to improve the quality of data, indicators of performance, tying performance to costs and outcomes, and working with clinicians and managers to create an interface between performance and quality of care. By understanding each other's work, we can maximize synergy and promote the public's interest in effective, efficient and equitable hospital care.
J. Ivan Williams, Ph.D.
President and CEO
Institute for Clinical
Who Is HEALNet and Why Should We Care?
s a member of the Editorial Board of Hospital Quarterly, I was invited to attend a conference sponsored by a group called HEALNet. The conference was held in Calgary on March 29 and 30. Now the first admission that I must make is that I did not know what HEALNet was, who was involved and what its objectives were. Still, it was an interesting invitation as I would be able to shed my normal role and attend in the cloak of a media representative.
What I learned at the HEALNet conference turned out to be most interesting. This relatively low-profile group is actually doing applied research into health outcomes in a manner that is directly applicable to health system operators, managers and policy makers. Unfortunately, very few of these individuals who could apply the research being conducted by HEALNet members were at the conference and, perhaps like myself, do not know of the work being carried out. Let me tell you more about HEALNet.
HEALNet stands for Health Evaluation Application and Linkage Network and they are a part of the Federal Networks of Centres of Excellence Programs, a federal policy initiative which brings together university, government and private-sector organizations. The work focuses on the use of and access to the best-available research evidence in the making of health planning, funding and delivery decisions at the clinical, administrative and policy levels. This sounds rather academic but in fact the projects currently underway in the Network focus on how research evidence in healthcare is generated and communicated, how health decisions are made and how performance in the health system is measured and improved. This group is doing applied research into health outcomes, and the results it is achieving would be of immediate interest and use by our health system managers and policy makers across the country - if they only knew it existed. Unfortunately, there is a gap between those doing the research and those who can apply it.
The list of individuals and organizations associated with HEALNet turns out to be very impressive. Representatives come from more than 20 Canadian universities, plus research institutes, federal and provincial departments and a variety of public and commercial partners. Individuals like Dr. Kathryn Hannah of Sierra Systems Consultants Inc. who is the current Board Chair and Mr. Ron Yamada of MDS, who is the past Chair, recognize the need to partner far more closely with healthcare organizations across Canada. Without mentioning all of the members of the Board, I do note that Mr. Dick Alvarez, CEO of CIHI, is involved and is highly supportive. I also note that individuals like Mr. Allan Nymark, Associate Deputy Minister, Health Canada, and Mr. Tom Closson, CEO of Victoria Capital Health Region, who both gave presentations at the conference, are also enthusiastic. On the other side, the obvious lack of attendance by health system managers was evident. There were only perhaps two or three senior health administrators who were even registered for the conference. This was unfortunate.
The point is this: We have a health system which is reeling with the strains of continuous evolution and looking for new and innovative ways to measure what it is doing. On the other hand, we have HEALNet which is taking an academic approach to researching real-life aspects of the health system, and potentially revealing information which can be directly applied to the operation of our health system and to the improvement in the efficacy, effectiveness and efficiency of that system. HEALNet needs direction from health system managers to help focus their initiatives, and health system managers need the information from HEALNet research to assist them in making more informed decisions. It is time that the two sides got together.
Thank you to HQ for the opportunity to attend this Conference and to express these thoughts.
About the Author(s)
President and CEO
Health Resources Group
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