How can we hold health care managers accountable if what they are managing cannot be measured? If we are to build a better health system, we need a better information sharing system so that all governments and all providers can be held accountable to Canadians.
- Roy J. Romanow, Building on Values: The Future of Health Care in Canada  

Public reporting of health system performance continues to gain prominence as an effective accountability technique in Canada and elsewhere. Its status has come as a result of its ability to respond to long-standing public expectations for transparency as well as policy and provider commitments to healthcare quality improvement.

Synonymous with report cards, public reporting is commonly thought to inform patient healthcare decision-making. However, the research evidence suggests Canadians are, for the most part, unenthusiastic when it comes to accessing health system performance indicators (Canadian Health Services Research Foundation [CHSRF] 2006). For example, in cardiovascular care, report cards have been available for more than a decade but with little use by patients (Bentley and Nash 1998). While research shows patients do not generally use report cards, it does show that healthcare providers and facilities use them to identify areas that are working well and areas where providers should consider making improvements (Bentley and Nash 1998; Scanlon et al. 2002; Tu and Cameron 2003).

Although riddled with some controversy over its use, public reporting is likely here to stay. According to a newly published synthesis, Public Reporting on the Quality of Healthcare: Emerging Evidence on Promising Practices for Effective Reporting, the most important question to ask about public reporting is not whetherit should be done but, rather, how it can be done effectively (Wallace et al. 2007). Commissioned by CHSRF, in partnership with the Ontario Health Quality Council, this research project aimed to promote a better understanding of the evidence around effective strategies and promising practices for public reporting on the quality of healthcare. In their report, Wallace, Teare, Verrall and Chan provide a comprehensive review of the literature and results of key informant interviews, which aimed to identify the key components of an effective public reporting program.  

Wallace et al. identify that in Canada, federal and provincial governments as well as independent or arm's-length agencies are undertaking different initiatives to report on healthcare quality by type of intervention or a specific disease. Despite this, the authors propose that there is no single "best" approach to reporting effectively. Rather, there are a number of factors to take into consideration to develop an effective reporting program, such as knowing the needs of the audience, defining clearly its objective and cultivating the media to be able to disseminate the right message.  

Understanding that one size does not fit all when it comes to public reporting on quality of care, Wallace et al. suggest a framework that incorporates six components for developing a public reporting program:  

1. Objectives. Defining the objectives of a report is the most important step in the process. The literature and Wallace et al.'s report identify that organizations typically report for three reasons: to improve accountability, quality and/or consumer choice.
2. Audience. The target audience is determined by the objectives of the reporting process and can vary depending on who is to be held accountable, how quality improvement can be addressed or whether consumer choice is the desired outcome.
3. Report content. The content of a report should be informed by the nature of the audience and what is to be accomplished. For example, if the intended audience is policy and decision-makers with a regional health authority, the content or indicators would be different from those in a report that is intended for clinical healthcare providers, such as nurses.
4. Product. The final product should be presented in such a way that is appropriate for and easily understood by the audience.  
5. Distribution. Reaching the target audience involves taking some weighted risks. For example, relying on passive channels of distribution - such as newspaper inserts, physician waiting rooms and libraries - imposes the risk of failure of the product reaching consumers of care. Meanwhile, other methods, such as engaging the news media to promote quality reporting, may get the product into consumers' hands but can take considerable effort and lead to the delivery of messages that are sensationalized or misrepresented.  
6. Impact. While there is some evidence to suggest that public reporting can lead to small improvements in the quality of care, there is no solid evidence of its impact on increasing or improving accountability in the health system. Full evaluations of the impact of reporting have been limited due to high costs.

Improving quality begins with an open and honest acknowledgement of where things are going well and not so well (Berwick 1989). With that mindset, Wallace et al. intend to start a discussion about improving the quality of care in Canada through reporting processes. However, the authors recognize that report cards are best considered one piece of the puzzle for improving quality.

To delve deeper into this discussion, the Foundation's theme officer for managing for quality and safety, Steeve Vigneault, along with the Canadian Patient Safety Institute, hosted a national workshop on public reporting on healthcare quality in November 2007 in Vancouver, British Columbia. The workshop aimed to promote knowledge sharing of promising practices and tacit knowledge on public reporting and to identify effective ways to continue to share such knowledge. One of the ways to continue these efforts was through gauging the interest of workshop participants - particularly, Canadian organizations involved in public reporting on healthcare quality - in taking part in future joint initiative(s) for collaboration and knowledge sharing on ways to improve public reporting of healthcare quality. For more information about the workshop on Public Reporting on Healthcare Quality, please contact Steeve Vigneault at steeve.vigneault@chsrf.ca. Meanwhile, to read Wallace et al.'s final report or other products on improving quality of care, visit https://www.chsrf.ca/research_themes/safety_e.php.  

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