Trust in performance indicators?

Impact of a Clinician Incentive Program on Quality Measures Performance in a Medicare Shared Savings Accountable Care Organization

Financial incentives are often used to encourage and reward clinicians for achieving specific outcomes; however, there is limited data on their effectiveness. This study evaluates the impact of NewYork Quality Care's Clinician Incentive Program on improving quality measure performance over 4 years. Clinicians including primary care physicians and specialists actively opted-in to an incentive program where their quality performance was evaluated and rewarded biannually. Using Medicare Shared Savings Program data extracted for quality measures (2016-2019), this study analyzes quality measure performance between clinicians who opted-in to the program compared to those who did not. Additional analysis was performed comparing primary care clinician and specialist performance. The analysis revealed that clinicians in the incentive program significantly outperform (P < 0.05) clinicians who chose not to join the program in 6 of the 7 quality measures. In addition, the program helped facilitate discussions with clinicians more broadly in population health efforts.

Health system performance assessment in small countries: The case study of Latvia

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision-making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence-based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness. Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks. Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country. As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.

Drug using parents: an exploration of family focused support from health professionals

The objective of this paper was to explore the challenges identified by four health professionals working with families who misuse drugs in relation to family parenting responsibilities. Participants included a midwife, a public health nurse, a general practitioner and a specialist addiction nurse. The paper explored self reflections by the participants of their practice in a primary care setting. Three challenges were identified: family focused care; ethical considerations; and the need for a supported learning environment. The paper proposes consideration of appropriately funded, mandatory joint training supported through a learning organisation approach within the NHS.

A comparison of hierarchical cluster analysis and league table rankings as methods for analysis and presentation of district health system performance data in Uganda

In 2003, the Uganda Ministry of Health introduced the district league table for district health system performance assessment. The league table presents district performance against a number of input, process and output indicators and a composite index to rank districts. This study explores the use of hierarchical cluster analysis for analysing and presenting district health systems performance data and compares this approach with the use of the league table in Uganda. Ministry of Health and district plans and reports, and published documents were used to provide information on the development and utilization of the Uganda district league table. Quantitative data were accessed from the Ministry of Health databases. Statistical analysis using SPSS version 20 and hierarchical cluster analysis, utilizing Wards' method was used. The hierarchical cluster analysis was conducted on the basis of seven clusters determined for each year from 2003 to 2010, ranging from a cluster of good through moderate-to-poor performers. The characteristics and membership of clusters varied from year to year and were determined by the identity and magnitude of performance of the individual variables. Criticisms of the league table include: perceived unfairness, as it did not take into consideration district peculiarities; and being oversummarized and not adequately informative. Clustering organizes the many data points into clusters of similar entities according to an agreed set of indicators and can provide the beginning point for identifying factors behind the observed performance of districts. Although league table ranking emphasize summation and external control, clustering has the potential to encourage a formative, learning approach. More research is required to shed more light on factors behind observed performance of the different clusters. Other countries especially low-income countries that share many similarities with Uganda can learn from these experiences.

Quality of care and quality of life: convergence or divergence?

The aim of this study was to explore the impact of quality of care (QoC) on patients' quality of life (QoL). In a cross-sectional study, two domains of QoC and the World Health Organization Quality of Life-Bref questionnaire were combined to collect data from 1,059 pre-discharge patients in four accredited hospitals (ACCHs) and four non-accredited hospitals (NACCHs) in Saudi Arabia. Health and well-being are often restricted to the characterization of sensory qualities in certain settings such as unrestricted access to healthcare, effective treatment, and social welfare. The patients admitted to tertiary health care facilities are generally able to present themselves with a holistic approach as to how they experience the impact of health policy. The statistical results indicated that patients reported a very limited correlation between QoC and QoL in both settings. The model established a positive, but ultimately weak and insignificant, association between QoC (access and effective treatment) and QoL (r = 0.349, P = 0.000; r = 0.161, P = 0.000, respectively). Even though the two settings are theoretically different in terms of being able to conceptualize, adopt, and implement QoC, the outcomes from both settings demonstrated insignificant relationships with QoL as the results were quite similar. Though modern medicine has substantially improved QoL around the world, this paper proposes that health accreditation has a very limited impact on improving QoL. This paper raises awareness of this topic with multiple healthcare professionals who are interested in correlating QoC and QoL. Hopefully, it will stimulate further research from other professional groups that have new and different perspectives. Addressing a transitional health care system that is in the process of endorsing accreditation, investigating the experience of tertiary cases, and analyzing deviated data may limit the generalization of this study. Global interest in applying public health policy underlines the impact of such process on patients' outcomes. As QoC accreditation does not automatically produce improved QoL outcomes, the proposed study encourages further investigation of the value of health accreditation on personal and social well-being.

Diabetic retinopathy care--an international quality comparison

PURPOSE

The purpose of this paper is to study the quality indicator appropriateness and use it for international quality comparison on diabetic retinopathy (DR) patient care process in one American and one Dutch eye hospital.

DESIGN/METHODOLOGY/APPROACH

A 17-item DR quality indicator set was composed based on a literature review and systematically applied in two hospitals. Qualitative analysis entailed document study and 12 semi-structured face-to-face interviews with ophthalmologists, managers, and board members of the two hospitals.

FINDINGS

While the medical-clinical approach to DR treatment in both hospitals was similar, differences were found in quality of care perception and operationalization. Neither hospital systematically used outcome indicators for DR care. On the process level, the authors found larger differences. Similarities and differences were found in the structure of both hospitals. The hospitals' particular contexts influenced the interpretation and use of quality indicators.

PRACTICAL IMPLICATIONS

Although quality indicators and quality comparison between hospitals are increasingly used in international settings, important local differences influence their application. Context should be taken into account. Since that context is locally bound and directly linked to hospital setting, caution should be used interpreting the results of quality comparison studies.

ORIGINALITY/VALUE

International quality comparison is increasingly suggested as a useful way to improve healthcare. Little is known, however, about the appropriateness and use of quality indicators in local hospital care practices.

Dissemination of performance information and continuous improvement: A narrative systematic review

PURPOSE

Developing a performance measure and reporting the results to support decision making at an individual level has yielded poor results in many health systems. The purpose of this paper is to highlight the factors associated with the dissemination of performance information that generate and support continuous improvement in health organizations.

DESIGN/METHODOLOGY/APPROACH

A systematic data collection strategy that includes empirical and theoretical research published from 1980 to 2010, both qualitative and quantitative, was performed on Web of Science, Current Contents, EMBASE and MEDLINE. A narrative synthesis method was used to iteratively detail explicative processes that underlie the intervention. A classification and synthesis framework was developed, drawing on knowledge transfer and exchange (KTE) literature. The sample consisted of 114 articles, including seven systematic or exhaustive reviews.

FINDINGS

Results showed that dissemination in itself is not enough to produce improvement initiatives. Successful dissemination depends on various factors, which influence the way collective actors react to performance information such as the clarity of objectives, the relationships between stakeholders, the system's governance and the available incentives.

RESEARCH LIMITATIONS/IMPLICATIONS

This review was limited to the process of knowledge dissemination in health systems and its utilization by users at the health organization level. Issues related to improvement initiatives deserve more attention.

PRACTICAL IMPLICATIONS

Knowledge dissemination goes beyond better communication and should be considered as carefully as the measurement of performance. Choices pertaining to intervention should be continuously prompted by the concern to support organizational action.

ORIGINALITY/VALUE

While considerable attention was paid to the public reporting of performance information, this review sheds some light on a more promising avenue for changes and improvements, notably in public health systems.

Analytical perspectives on performance-based management: an outline of theoretical assumptions in the existing literature

Performance-based management (PBM) has become a dominant form of governance in health care and there is a need for careful assessment of its function and effects. This article contains a cross-disciplinary literature synthesis of current studies of PBM. Literature was retrieved by database searches and categorized according to analytical differences and similarities concerning (1) purpose and (2) governance mechanism of PBM. The literature could be grouped into three approaches to the study of PBM, which we termed: the ‘functionalist’, the ‘interpretive’ and the ‘post-modern’ perspective. In the functionalist perspective, PBM is perceived as a management tool aimed at improving health care services by means of market-based mechanisms. In the interpretive perspective, the adoption of PBM is understood as consequence of institutional and individual agents striving for public legitimacy. In the post-modern perspective, PBM is analysed as a form of governance, which has become so ingrained in Western culture that health care professionals internalize and understand their own behaviour and goals according to the values expressed in these governance systems. The recognition of differences in analytical perspectives allows appreciation of otherwise implicit assumptions and potential implications of PBM. Reflections on such differences are important to ensure vigilant appropriation of shifting management tools in health quality governance.

The Teacher and the Cop: The Role of ‘Private Space in Increasingly Transparent Clinical Practice

Education and enforcement have been two contrasting ways of managing clinical performance. Both are needed but recently health policy has placed greater emphasis on the latter, possibly to the detriment of the former. This paper examines the ways in which education and other formative aspects of clinical practice can be conducted. The boundary between education and enforcement involves a distinction between public and private space. Private space is the territory within which clinicians can review their performance and improve it from an educational perspective. The boundary between public and private space is fluid, particularly since the advent of systems to ensure clinicians' competence. The sensitive management of this boundary will determine whether the benefits of transparent clinical practice will be realized in terms of improved patient care.

Gaming in infection control: a qualitative study exploring the perceptions and experiences of health professionals in Mongolia

BACKGROUND

This study aimed to gain insight into the extent to which gaming is responsible for the underreporting of hospital-acquired infections (HAIs) in Mongolian hospitals, to identify gaming strategies used by health professionals, and to determine how gaming might be prevented.

METHODS

Eighty-seven health professionals, including policy- and hospital-level managers, doctors, nurses, and infection control practitioners, were recruited for 55 interviews and 4 group discussions in Mongolia in 2008.

RESULTS

All study participants were aware of gaming, which could occur via the following mechanisms: (1) doctors or nurses concealing HAI by overprescribing antibiotics or discharging patients early; (2) infection control practitioners failing to report HAI cases to hospital directors; and (3) hospital directors preventing reporting of HAI cases to the Ministry of Health. Gaming was consistently perceived to be a response to punitive performance evaluation by the Ministry of Health and penalization of hospitals and staff by the State Inspection Agency when HAIs were detected. Participants held divergent views regarding the best approach to reduce gaming, including excluding the current single indicator (ie, HAI rate) from the performance indicator list, developing multiple specific infection control indicators, improving the awareness of health managers regarding the causes of HAI, and increasing funding for infection control activities.

CONCLUSION

Inclusion of the overall HAI rate in the targeted performance indicator set and the strict control and penalization of hospitals with reported HAI cases are factors that have contributed to gaming, which has resulted in deliberate, extreme underreporting of HAIs in Mongolian hospitals.

The National Bowel Cancer Audit: the risks and benefits of moving to open reporting of clinical outcomes

BACKGROUND

The government's proposals to openly report clinical outcomes poses challenges to the National Bowel Cancer Audit now funded by the UK department of health.

AIM

To identify the benefits and risks of open reporting and to propose ways the risks might be minimized.

METHODS

A review of the literature on clinical audit and the consequences of open reporting.

RESULTS

There are significant potential benefits of a national audit of bowel cancer including protecting patients from sub-standard care, providing clinicians with externally validated evidence of their performance, outcome data for clinical governance and evidence that increases in government expenditure are achieving improvements in survival from bowel cancer. These benefits will only be achieved if the audit captures most of the cases of bowel cancer in the UK, the data collected is complete and accurate, the results are risk adjusted and these are presented to the public in a way that is fair, clear and understandable. Involvement of clinicians who have confidence in the results of the audit and who actively compare their own results against a national standard is essential. It is suggested that a staged move to open reporting should minimise the risk of falsely identifying an outlying unit.

CONCLUSION

The fundamental aim of the National Bowel Cancer Audit is the pursuit of excellence by identification and adoption of best practice. This could achieve a continuous improvement in the care of all patients with bowel cancer in the UK. The ACPGBI suggests a safer way of transition to open reporting to avoid at least some of its pitfalls.

Clinical performance indicators: intolerance for variety?

PURPOSE

The performance of NHS U.K. hospitals is under continuous scrutiny as they are constantly under pressure to perform well. A recent document published by an independent body has recommended a host of clinical indicators to assess non-financial performance of hospitals. This study aims to critically analyse the performance of a single U.K. hospital against several of these recommended indicators.

DESIGN/METHODOLOGY/APPROACH

Data presented to the Hospital Trust Board for 12 months were used for this study. Previous years' data were used wherever available.

FINDINGS

Based on data analysis, this hospital's performance is extremely difficult to calculate. The indicators use complex ratios and due to lack of standardisation, the hospital performance could be interpreted as better, worse or indifferent.

RESEARCH LIMITATIONS/IMPLICATIONS

This study analyses most of the recommended indicators. Literature review did not reveal a similar analysis of another hospital against these indicators which precludes comparison.

PRACTICAL IMPLICATIONS

This study highlights the difficulty in comparing the performance of hospitals due to the inherent lack of consistency. Therefore it is apparent that any reward-rebuke system linked to performance should interpret the data with caution. It is therefore suggested that easy to control single value activities and standardised routine activities could be used to measure hospital performance. Alternatively, the hospital could compare with its own statistics from previous years.

ORIGINALITY/VALUE

Literature acknowledges the difficulties in measuring clinical performance. This paper elucidates these difficulties applied to the NHS and suggests alternatives.

Publishing outcome data: is it an effective approach?

RATIONALE, AIMS AND OBJECTIVES

The publication of health outcome data--rather than merely the measurement and collection--is being given increasing consideration. Publication reflects society's increasing emphasis on a general 'right to know', as well as being a means of informing consumer choice. In theory, publication may help to promote public trust, support patient choice, and stimulate action to improve the quality of care whilst controlling costs.

METHODS

Drawing on a literature review, this paper overviews the strategies employed in the UK and US to publish outcome data. The focus is on outcomes, and certain related process measures, that measure the performance of hospitals or surgeons.

RESULTS AND CONCLUSIONS

Presenting the limited evidence that exists, we review the potential beneficial and harmful effects of publishing hospital outcome data. We also consider the risks of making incorrect inferences based on these data and the potential for dysfunctional consequences. Recognizing that the public largely mistrusts currently published health outcome data, we offer some recommendations for the future direction of strategies for publication.

Theory and practice of waiting time data as a performance indicator in health care

In this article we investigate the use of waiting time data as a performance indicator in health care in The Netherlands. We explain why the current publication of waiting time data fails to achieve one of the main goals: to have consumers and general practitioners act upon this information. The reason, we claim, is that even seemingly clear-cut, easily measurable and objective numbers such as waiting times need interpretation to become meaningful. Discussing four themes - the patient behind the number, the treatment behind the number, the strategy behind the number, and the specificity of the number - we will discuss just how deeply this need for interpretation affects the usability of 'waiting times' for purposes such as informing consumers. We will argue that this problem is due to not making a clear distinction between performance indicators for internal use and for external use. We conclude that the usefulness of the publication of waiting time data for consumers strongly increases when waiting times are guaranteed and related to treatment options like booking possibilities and other performance indicators such as patient satisfaction.

Clinical governance and the learning organization

AIM

This paper compares and contrasts clinical governance and organizational learning.

BACKGROUND

Clinical governance represents one of the most significant policy developments in recent years. It places on all health care delivery organizations a statutory duty to develop the systems, standards and processes necessary to improve health care quality and manage risk. At the same time, many health care organizations are seeking new ways in which learning can be retained and deployed more widely within the organization (organizational learning).

KEY ISSUES

Both approaches emphasize cultural changes as essential underpinnings to quality improvement. However, the two approaches also differ fundamentally in their logic of action. Clinical governance is essentially 'top down', being built around formal standards, established procedures, and regular monitoring and reporting. In contrast, organizational learning emphasizes 'bottom up' changes in values, beliefs and motivations in such a way that learning and change are prioritized. The challenge for managers and practitioners lies in seeking a creative tension between these two contrasting styles of organizational change.

The role of performance indicators in changing the autonomy of the general practice profession in the UK

Performance indicators (PIs) are widely used across the UK public sector, but they have only recently been applied to clinical care. In doing so, they challenge a previously guarded aspect of clinical autonomy-the assessment of work performance. This "challenge" is specific to a primary care setting and in the general practice profession. This paper reviews the qualitative findings from an empirical study within one English primary care group on the response to a set of clinical PIs relating to general practitioners (GPs) in terms of the effect upon their clinical autonomy. Prior to interviews with GPs, primary care teams received feedback on their clinical performance as judged by indicators. Five themes were crucial in understanding GPs responses: the credibility of PIs, the growing need to demonstrate competence, perceptions of autonomy, the ulterior purpose of PIs, and the identity of the assessor of their performance. PIs are playing a key role in changing the locus of performance assessment along two dimensions: location and expertise. As the locus helps to determine the nature of clinical autonomy, it is likely to have implications for the nature of the general practice profession.

The PATRIARCH Study. Using outcome measures for league tables: can a North American prediction of admission score be used in a United Kingdom children's emergency department? PRISA And Triage In A Regional Children's Hospital

OBJECTIVES

The use of league tables has become predominant in the healthcare culture of the United Kingdom. These tables are often based on measures that are viewed with scepticism by clinicians. This study was designed to test the validity of a North American risk of admission score, the PRISA, for use in a United Kingdom population of accident and emergency (A&E) attendees.

METHODS

All attendees to a children's A&E department were scored using the PRISA for a single calendar month (November 2000)

RESULTS

701 children were studied in total. The results show that the PRISA applied to this population gives an area under the receiver operator curve of 0.76. Of the 701 patients studied, 206 (29.4%) were admitted. The PRISA predicted a total of 206.10 admissions. Of the 50 patients discharged with the highest PRISA scores (that is, with the highest likelihood of admission), none were admitted in the 48 hours after their original attendance.

CONCLUSIONS

These results show that the PRISA is suitable as a measure of paediatric A&E department performance in the United Kingdom and it is highly promising as a future measure of quality.

Health care report cards: implications for vulnerable patient groups and the organizations providing them care

Standardized public reporting on the quality of health care (report cards) offers an opportunity to empower purchasers and consumers so that they can make choices that can result in better health care for less money. However, not all population subgroups are equally well served by the publication of such data. In particular, vulnerable patient groups such as the poor, the less educated, the chronically sick, and members of ethnic or linguistic minorities may find issues of importance to them largely neglected. In addition, the way that report card data are collected, analyzed, and presented may further marginalize the experiences of these groups who in any case are already underserved by the health system. This observation also has important implications for health care providers who serve primarily large numbers of vulnerable patients. The differential impacts of report card data on vulnerable patient groups (and their providers) need to be addressed by researchers and policy makers if access issues are not to be damaged further by the providers' pursuit of quality and value.

Reporting health care performance: learning from the past, prospects for the future

In the USA, where public reporting of data on clinical performance is most advanced, comparative performance information, in the form of 'report cards', 'provider profiles' and 'physician profiling', has been published for over a decade. Many other countries are now following a similar route and are seeking to develop comparative data on health care performance. Notwithstanding the idiosyncratic nature of US health care, and the implications this has for the generalizability of findings from the USA to other countries, it is pertinent to ask what other countries can learn from the US experience. Based on a series of structured interviews with leading experts on the US health system, this article draws out the key lessons for other countries as they develop similar policies in this area. This paper highlights three concerns that have dominated the development of adequate measures in the USA, and that require consideration when developing similar schemes elsewhere. Firstly, the need to develop indicators with sound metric properties - high in validity and meaningfulness, and appropriately risk-adjusted. Secondly, the need to involve all stakeholders in the design of indicators, and a requirement that those measures be adapted to different audiences. Thirdly, a need to understand the needs of end users and to engage with them in partnerships to increase the attention paid to measurement. This study concludes that the greatest challenge is posed by the desire to make comparative performance data more influential in leveraging performance improvement. Simply collecting, processing, analysing and disseminating comparative data is an enormous logistical and resource-intensive task, yet it is insufficient. Any national strategy emphasizing comparative data must grapple with how to engage the serious attention of those individuals and organizations to whom change is to be delivered.

Public release of performance data and quality improvement: internal responses to external data by US health care providers

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.

Developing organizational learning in the NHS

Learning has been identified as a central concern for a modernized NHS. Continuing professional development has an important role to play in improving learning but there is also a need to pay more attention to collective (organizational) learning. Such learning is concerned with the way organizations build and organize knowledge. Recent emphasis within the NHS has been on the codification of individual and collective knowledge - for example, guidelines and National Service Frameworks. This needs to be balanced by more personalized knowledge management strategies, especially when dealing with innovative services that rely on tacit knowledge to solve problems. Having robust systems for storing and communicating knowledge is only one part of the challenge. It is also important to consider how such knowledge gets used, and how routines become established within organizations that structure the way in which knowledge is deployed. In many organizations these routines favour the adaptive use of knowledge, which helps organizations to achieve incremental improvements to existing practices. However, the development of organizational learning in the NHS needs to move beyond adaptive (single loop) learning, to foster skills in generative (double loop) learning and meta-learning. Such learning leads to a redefinition of the organization's goals, norms, policies, procedures or even structures. This paper argues that moving the NHS in this direction will require attention to the cultural values and structural mechanisms that facilitate organizational learning.

Big bang and the policy prescription: health care meets the market in New Zealand

This article discusses events that led up to and the aftermath of New Zealand's radical health sector restructuring of 1993. It suggests that "big bang" policy change facilitated the introduction of a set of market-oriented ideas describable as a policy prescription. In general, the new system performed poorly, in keeping with problems of market failure endemic in health care. The system was subsequently restructured, and elements of the 1993 structures were repackaged through a series of incremental changes. Based on the New Zealand experience, big bang produces change but not necessarily a predictive model, and the policy prescription has been oversold.

Clinical governance: bridging the gap between managerial and clinical approaches to quality of care

Clinical governance has been introduced as a new approach to quality improvement in the UK national health service. This article maps clinical governance against a discussion of the four main approaches to measuring and improving quality of care: quality assessment, quality assurance, clinical audit, and quality improvement (including continuous quality improvement). Quality assessment underpins each approach. Whereas clinical audit has, in general, been professionally led, managers have driven quality improvement initiatives. Quality assurance approaches have been perceived to be externally driven by managers or to involve professional inspection. It is discussed how clinical governance seeks to bridge these approaches. Clinical governance allows clinicians in the UK to lead a comprehensive strategy to improve quality within provider organisations, although with an expectation of greatly increased external accountability. Clinical governance aims to bring together managerial, organisational, and clinical approaches to improving quality of care. If successful, it will define a new type of professionalism for the next century. Failure by the professions to seize the opportunity is likely to result in increasingly detailed external control of clinical activity in the UK, as has occurred in some other countries.

Improving quality in general practice: qualitative case study of barriers faced by health authorities

OBJECTIVES

To identify and assess the barriers that health authorities face as they manage quality improvements in general practice in the context of the NHS reforms.

DESIGN

Qualitative case study.

SETTING

Three UK health authorities: a rural health authority in the south west, a deprived inner city health authority in the north east, and an affluent suburban health authority in the south east.

PARTICIPANTS

Senior and junior managers.

MAIN OUTCOME MEASURES

Structure of strategic and organisational management, and barriers to the leadership and management of quality improvement in general practice.

RESULTS

Seven barriers were identified: absence of an explicit strategic plan for general practice, competing priorities for attention of the health authority, sensitivity of health professionals, lack of information due to poor quality of clinical data, lack of authority to implement change, unclear roles and responsibilities of managers within the organisations, and isolation from other authorities or organisations facing similar challenges.

CONCLUSIONS

The health authorities faced significant barriers that would impede their ability to fulfil their responsibilities in the new NHS and that would reduce their capacity to contribute to quality improvements in general practice.

Performance management using health outcomes: in search of instrumentality

The past decade has seen the growing use of performance data in the hope of bringing about quality improvements in health care. Most recently, an emphasis on health outcomes (and especially mortality rates) has led to much activity around collecting and publishing such data. Two major problems intervene. What meanings can be ascribed to reported health outcomes? And what impacts are they likely to have on clinical performance? Much empirical work supports the assertion that reported outcomes may be poor indicators of service quality. In addition, the impact of these data may be small or even detrimental unless great care is made to connect the reporting with explicit quality-improving actions.