Measuring the performance of health systems

A Comprehensive Evaluation of Township Hospitals in the Severely Cold Areas of China

OBJECTIVE

The aims of this study are to establish an evaluation system and find the existing problems in the architectural design of township hospitals in the severely cold regions of China.

BACKGROUND

Due to the geographical location and economic factors, development still has some key problems, such as inadequate construction, old facilities, and backward technology, which are more prominent in the severely cold regions.

METHODS

First, evaluation factors have been selected and determined by literature review and on-site investigation. Evaluation rules have been determined using fuzzy membership function. Then, the analytic hierarchy process is used to determine the weights of the evaluation factors at all levels. Finally, take a township hospital as an example to calculate the comprehensive evaluation results.

RESULTS

A comprehensive evaluation index system with 28 elements and 76 factors for the township hospitals in severely cold regions including the basic health service capacity, the emergency capacity, and the climate fitness.

CONCLUSIONS

The establishment of the comprehensive evaluation system of township hospitals in severely cold areas in this study aims to find out the problems through the evaluation of the existing township hospitals in the severely cold areas and provide guidance for the transformation of existing township hospitals in the severely cold areas. By comparing the scheme evaluation for building hospitals, we shall look for the optimal solution to provide reference for future development in the construction of township hospitals.

Ranked Performance of Canada's Health System on the International Stage: A Scoping Review

Introduction:

Since the release of the World Health Report in 2000, health system performance ranking studies have garnered significant health policy attention. However, this literature has produced variable results. The objective of this study was to synthesize the research and analyze the ranked performance of Canada's health system on the international stage.

Method:

We conducted a scoping review exploring Canada's place in ranked health system performance among its peer Organisation for Economic Co-operation and Development countries. Arksey and O'Malley's five-stage scoping review framework was adopted, yielding 48 academic and grey literature articles. A literature extraction tool was developed to gather information on themes that emerged from the literature.

Synthesis:

Although various methodologies were used to rank health system performance internationally, results generally suggested that Canada has been a middle-of-the-pack performer in overall health system performance for the last 15 years. Canada's overall rankings were 7/191, 11/24, 10/11, 10/17, “Promising” and “B” grade across different studies. According to past literature, Canada performed well in areas of efficiency, productivity, attaining health system goals, years of life lived with disability and stroke mortality. By contrast, Canada performed poorly in areas related to disability-adjusted life expectancy, potential years of life lost, obesity in adults and children, diabetes, female lung cancer and infant mortality.

Conclusion:

As countries introduce health system reforms aimed at improving the health of populations, international comparisons are useful to inform cross-country learning in health and social policy. While ranking systems do have shortcomings, they can serve to shine a spotlight on Canada's health system strengths and weaknesses to better inform the health policy agenda.

Complication Rates, Hospital Size, and Bias in the CMS Hospital-Acquired Condition Reduction Program

In 2016, Medicare’s Hospital-Acquired Condition Reduction Program (HAC-RP) will reduce hospital payments by $364 million. Although observers have questioned the validity of certain HAC-RP measures, less attention has been paid to the determination of low-performing hospitals (bottom quartile) and the assignment of penalties. This study investigated possible bias in the HAC-RP by simulating hospitals’ likelihood of being in the worst-performing quartile for 8 patient safety measures, assuming identical expected complication rates across hospitals. Simulated likelihood of being a poor performer varied with hospital size. This relationship depended on the measure’s complication rate. For 3 of 8 measures examined, the equal-quality simulation identified poor performers similarly to empirical data (c-statistic approximately 0.7 or higher) and explained most of the variation in empirical performance by size (Efron’s R2 > 0.85). The Centers for Medicare & Medicaid Services could address potential bias in the HAC-RP by stratifying by hospital size or using a broader “all-harm” measure.

Developing a dashboard to help measure and achieve the triple aim: a population-based cohort study

BACKGROUND

Health system planners aim to pursue the three goals of Triple Aim: 1) reduce health care costs; 2) improve population health; and 3) improve the care experience. Moreover, they also need measures that can reliably predict future health care needs in order to manage effectively the health system performance. Yet few measures exist to assess Triple Aim and predict future needs at a health system level. The purpose of this study is to explore the novel application of a case-mix adjustment method in order to measure and help improve the Triple Aim of health system performance.

METHODS

We applied a case-mix adjustment method to a population-based analysis to assess its usefulness as a measure of health system performance and Triple Aim. The study design was a retrospective, cohort study of adults from Ontario, Canada using administrative databases: individuals were assigned a predicted illness burden score using a case-mix adjustment system from diagnoses and health utilization data in 2008, and then followed forward to assess the actual health care utilization and costs in the following year (2009). We applied the Johns Hopkins Adjusted Clinical Group (ACG) Case-Mix System to categorize individuals into 60 levels of healthcare need, called ACGs. The outcomes were: 1) Number of individuals per ACG; 2) Total system costs per ACG; and 3) Mean cost per person per ACG, which together formed a health system "dashboard".

RESULTS

We identified 11.4 million adults. 16.1% were aged 65 or older, 3.2 million (28%) did not use health care services that year, and 45,000 (0.4%) were in the highest acuity ACG category using 12 times more than an average adult. The sickest 1%, 5% and 15% of the population use about 10%, 30% and 50% of total health system costs respectively. The dashboard measures 2 dimensions of Triple Aim: 1) reduced costs: when total system costs per ACG or when average costs per person is reduced; and 2) improved population health: when more people move into healthier rather than sicker ACGs. It can help to achieve the third aim, improved care experience, when ACG utilization predictions are reported to providers to proactively develop care plans.

CONCLUSIONS

The dashboard, developed via case-mix methods, measures 2 of the Triple Aim goals and can help health system planners better manage their health delivery systems.

Quality initiatives: Key performance indicators for measuring and improving radiology department performance

Key performance indicators (KPIs) are financial and nonfinancial measures that are used to define and evaluate the success of an organization. KPIs differ, depending on the nature of the organization and the organizational strategy; they are devised to help evaluate the progress of an organization toward achieving its long-term goals and fulfilling its vision. In healthcare organizations, performance assessment is especially critical for the development of best practices that can lead to improved outcomes in patient care, and KPIs have been incorporated into many healthcare management systems. In the future, radiology-specific KPIs such as those in use at the authors' institution may help provide a framework for measuring performance in radiology practice.

Palliative care teams: Effective through moral reflection

Working as a multidisciplinary or interdisciplinary team is an essential condition to provide good palliative care. This widespread assumption is based on the idea that teamwork makes it possible to address the various needs of the patient and family more effectively. This article is about teamwork and about the effectiveness of teams working in palliative care. First, the nature of teamwork will be highlighted. Second, attention will be paid to team effectiveness; what exactly is team effectiveness and with what parameters can it be measured? Third, the nature of moral reflection and moral deliberation in palliative care will be highlighted. A concrete process of moral deliberation will be described. In conclusion, we shall argue that the capacity for moral reflection is a feature of a team working effectively.

How responsive Turkish health care system is to its citizens: the views of hospital managers

With this paper it was tried to give a broad perspective about the responsiveness level of Turkish health care system, and how Turkish health care system meets the expectations of its citizens. For achieving the main purpose of this study a sample of hospital managers (n = 172) was selected, and the responsiveness questionnaire developed by WHO was administered. If the responsiveness level of Turkish health care system is measured on the basis of the Turkish hospital managers' views in the sample by using the weights reported in the World Health Report 2000, responsiveness level is calculated as 6.14, and Turkey's place should be 35 rather than 93 among 191 countries. The findings showed that Turkish health care system met confidentiality expectations of Turkish citizens better than other expectations for other aspects of responsiveness. In light of the main results of this study we conclude that the economic status, demographic structure, culture, and some other regional and country-specific factors should be taken into account by calculating and especially ranking the countries according to responsiveness level of their health care systems, and each country should carry out this kind of studies by using the views of their own key informants or preferably citizens, if possible.

Bedside, classroom and bench: collaborative strategies to generate evidence-based knowledge for nursing practice

The rise of evidence-base practice (EBP) as a standard for care delivery is rapidly emerging as a global phenomenon that is transcending political, economic and geographic boundaries. Evidence-based nursing (EBN) addresses the growing body of nursing knowledge supported by different levels of evidence for best practices in nursing care. Across all health care, including nursing, we face the challenge of how to most effectively close the gap between what is known and what is practiced. There is extensive literature on the barriers and difficulties of translating research findings into practical application. While the literature refers to this challenge as the "Bench to Bedside" lag, this paper presents three collaborative strategies that aim to minimize this gap. The Bedside strategy proposes to use the data generated from care delivery and captured in the massive data repositories of electronic health record (EHR) systems as empirical evidence that can be analysed to discover and then inform best practice. In the Classroom strategy, we present a description for how evidence-based nursing knowledge is taught in a baccalaureate nursing program. And finally, the Bench strategy describes applied informatics in converting paper-based EBN protocols into the workflow of clinical information systems. Protocols are translated into reference and executable knowledge with the goal of placing the latest scientific knowledge at the fingertips of front line clinicians. In all three strategies, information technology (IT) is presented as the underlying tool that makes this rapid translation of nursing knowledge into practice and education feasible.

Discrepancies between classification systems of childhood obesity

Despite growing concern about weight-related problems among children, no universally accepted classification system for childhood obesity exists. There is a number of proposed international body mass index (BMI)-based systems in use and national variants also exist in many countries. The absence of a universally accepted standard and confusion concerning which classification system to use on national levels complicate monitoring of the development of the obesity epidemic, stratification for selective interventions in public health, screening in clinical practice and comparisons between studies. Some proposed international classification systems have not only been recommended for global monitoring and comparisons between studies, but also for clinical and national epidemiological use in some countries. Possible discrepancies may thereby lead to inefficiencies in health care delivery and prevention programmes. The problems associated with misclassification of individuals at risk may lead to overconsumption of health care resources by lower-risk individuals and underconsumption by higher-risk individuals, which is costly both in terms of foregone health improvements and in terms of wasteful monetary usage. The aim of this paper was to review the specific problems associated with BMI as a measure of adiposity in childhood, the most commonly used classification systems for childhood obesity based on BMI, and how their performance can be evaluated.

Implications of the prevalence of stunting, overweight and obesity amongst South African primary school children: a possible nutritional transition?

OBJECTIVE

To investigate the relationship between stunting and levels of overweight/obesity among South African school children, using two definitions of overweight and obesity, based on the WHO and International Obesity Task Force (IOTF) criteria.

DESIGN

Cross-sectional descriptive analysis of the nutritional status of primary school children, using primary data from a rural community-based study undertaken in 1995 and secondary data from the South African National Primary Schools (SANPS) survey conducted in 1994. Stunting was measured according to the WHO definition of -2 Z scores height-for-age. Two sets of criteria were used to measure overweight and obesity-the WHO/NCHS standard based on the 85th and 95th centiles and the IOTF criteria.

SETTING

The primary data source was from a rural KwaZulu-Natal community based survey. The secondary data source SANPS consisted of data at National and Provincial level; for this study only data from the province of KwaZulu-Natal was considered.

SUBJECTS

Primary school children aged between 8 and 11 y of age; 802 from the primary data source and 24 391 from the secondary source.

RESULTS

Moderate stunting ranged from 2.9 to 40.2%, and mild stunting ranged from 31.4 to 75%. The prevalence of overweight ranged from 0.4 to 13.3% (WHO criteria) and from 0.4 to 11.9% using the IOTF criteria; while obesity ranged from 0.1 to 3.7% (WHO) and from 0.1 to 1.5% (IOTF criteria). The prevalence of overweight and obesity was observed to be higher using the WHO definition than that of IOTF (0.05<P<0.10). However, good kappa coefficient (kappa) levels of agreement were observed between the WHO and IOTF definitions of overweight and obesity (kappa>0.55, in all cases). The levels of agreement in all cases were less for obesity than overweight (both ranged from 0.55 to 1.0). Females were observed to have higher kappa levels than their male counterparts; they also had higher prevalence levels of overweight and obesity across age and geographical group. Uniformly high levels of both mild and moderate stunting were observed both nationally and provincially. However, no excess relative risk of being overweight if stunted was observed in this study (P>0.05).

CONCLUSIONS

Caution must be applied when using either definition for obesity. However, very high levels of agreement occur for overweight. There is no obvious relationship between overweight and stunting in this study, but high levels of mild stunting were observed. Regular clinical and epidemiological monitoring of nutritional status needs to be undertaken in South Africa to examine possible future trends of overweight/obesity and their relationship with stunting, and for comparisons with global trends.

Can health care quality indicators be transferred between countries?

OBJECTIVE

To evaluate the transferability of primary care quality indicators by comparing indicators for common clinical problems developed using the same method in the UK and the USA.

METHOD

Quality indicators developed in the USA for a range of common conditions using the RAND-UCLA appropriateness method were applied to 19 common primary care conditions in the UK. The US indicators for the selected conditions were used as a starting point, but the literature reviews were updated and panels of UK primary care practitioners were convened to develop quality indicators applicable to British general practice.

RESULTS

Of 174 indicators covering 18 conditions in the US set for which a direct comparison could be made, 98 (56.3%) had indicators in the UK set which were exactly or nearly equivalent. Some of the differences may have related to differences in the process of developing the indicators, but many appeared to relate to differences in clinical practice or norms of professional behaviour in the two countries. There was a small but non-significant relationship between the strength of evidence for an indicator and the probability of it appearing in both sets of indicators.

CONCLUSION

There are considerable benefits in using work from other settings in developing measures of quality of care. However, indicators cannot simply be transferred directly between countries without an intermediate process to allow for variation in professional culture or clinical practice.

Clinical nurse specialists in palliative care. Part 2. Explaining diversity in the organization and costs of Macmillan nursing services

In the UK, the work of Macmillan clinical nurse specialists in palliative care is now well established. There has been little research, however, into the organizational context in which these nurses operate and the implications for the services they deliver. We report on a major evaluation of the service delivery, costs, and outcomes of Macmillan nursing services in hospital and community settings. The study was based on eight weeks of fieldwork in each of 12 selected services. Data are presented from semi-structured interviews, clinical records, and cost analysis. We demonstrate wide variation across several dimensions: location and context of the services; activity levels; management patterns; work organization and content; links with other colleagues; and resource use. We suggest that such variation is likely to indicate the existence of both excellent practice and suboptimal practice. In particular, our study highlights problems in how teamwork is conceptualized and delivered. We draw on recent organizational theories to make sense of the heterogeneous nature of Macmillan nursing services.

Factoring socioeconomic status into cardiac performance profiling for hospitals: does it matter?

BACKGROUND

Critics of "scorecard medicine" often highlight the incompleteness of risk-adjustment methods used when accounting for baseline patient differences. Although socioeconomic status is a highly important determinant of adverse outcome for patients admitted to the hospital with acute myocardial infarction, it has not been used in most risk-adjustment models for cardiovascular report cards.

OBJECTIVES

To determine the incremental impact of socioeconomic status adjustments on age, sex, and illness severity for hospital-specific 30-day mortality rates after acute myocardial infarction.

METHODS

The authors compared the absolute and relative hospital-specific 30-day acute myocardial infarction mortality rates in 169 hospitals throughout Ontario between April 1, 1994 and March 31, 1997. Patient socioeconomic status was characterized by median neighborhood income using postal codes and 1996 Canadian census data. They examined two risk-adjustment models: the first adjusted for age, sex, and illness severity (standard), whereas the second adjusted for age, sex, illness severity, and median neighborhood income level (socioeconomic status).

RESULTS

There was an extremely strong correlation between 'standard' and 'socioeconomic status' risk-adjusted mortality rates (r = 0.99). Absolute differences in 30-day risk-adjusted mortality rates between the socioeconomic status and standard risk-adjustment models were small (median, 0.1%; 25th-75th percentile, 0.1-0.2). The agreement in the quintile rankings of hospitals between the socioeconomic status and standard risk-adjustment models was high (weighted kappa = 0.93).

CONCLUSION

Despite its importance as a determinant of patient outcomes, the effect of socioeconomic status on hospital-specific mortality rates over and above standard risk-adjustment methods for acute myocardial infarction hospital profiling in Ontario was negligible.