The Australian Healthcare and Hospitals Association held a “health reform simulation” in Canberra last week, with the aim of road-testing health reform plans and identifying some of the challenges around implementation.
Following a preliminary Croakey report on the proceedings, we now have further analysis from one of the participants, Dr Sharon Willcox, a health policy consultant and a commissioner of the former National Health and Hospitals Reform Commission.
She examines some of the challenges surrounding the “alphabet soup” of performance reporting agencies, and suggests we need a culture that values open debate and innovation.
How can we make best use of performance reporting?
Sharon Willcox writes:
One of the major elements of national health reform being put to the test at the AHHA’s recent simulation workshop was the role of the alphabet soup of existing and planned national performance reporting agencies.
Joining the veteran Australian Institute of Health and Welfare (AIHW) and the teenage Australian Commission on Safety and Quality in Health Care (ACSQHC) are the toddler COAG Reform Council (CRC) (established in 2007) and the embryonic National Health Performance Authority (NHPA) (with enabling legislation still to be passed).
Some of the challenges – and potential lessons – for these performance agencies identified at the AHHA simulation workshop are outlined below.
‘Assisting, not only assessing’ performance
The logic driving the establishment of the NHPA is that improved transparency and public reporting will automatically drive better performance. But, workshop participants argued the need to ‘close the loop’, drawing on the well-known continuous improvement cycle of ‘plan, do, study, act’.
One obvious gap is that none of the agencies (with the possible exception of ACSQHC) have any remit beyond identifying ‘good’ and ‘poor’ performing health services. The workshop identified the value of a ‘national service improvement’ function, so that poor performing health services were assisted in learning about best practice initiatives that had been effective in other health services.
Avoiding a blame-focussed performance culture
In a similar vein, there was strong consumer and clinician support for the view that health services should not be blamed for poor performance, but helped to improve.
Consumers were particularly concerned that ‘naming and shaming’ of Local Hospital Networks and Medicare Locals that did not meet performance targets might result in withdrawal of funding, causing these health services to fall even further behind. Instead, there should be capacity-building for less well-performing health services, providing them with tools and resources to encourage improvement.
Managing performance across the entire performance cycle
Many of the new performance agencies focus squarely on health outcome indicators relating to access and quality issues (such as the new four-hour emergency target). But, workshop participants urged the performance agencies to adopt a broad approach that gave equal weight to measurement of consumer experience.
There was also recognition that with the establishment of new agencies such as Medicare Locals, the initial focus of performance management should include ‘process’ measures, not only health outcome measures. Citing Steve Leeder in his absence (‘the target matters, but so does the archery’), workshop participants suggested that building collaborative relationships between LHNs, Medicare Locals and other health, community and aged care services was an essential first step in the long journey of health system reform.
Including the private sector
Historically, most health performance reporting has been at the level of states and territories (such as the annual Report on Government Services) and has focussed mainly on public hospitals. The new NHPA will produce Hospital Performance Reports (with information on each Local Hospital Network and individual public and private hospitals) and Healthy Community Reports (with information on the performance of Medicare Locals and measurement of the health of local communities).
Workshop participants suggested that, to date, there had been only limited engagement with the private sector (private hospitals, private specialists, GPs) by the performance agencies. Consumers and clinicians want access to performance data about all parts of the health system, not just public hospitals.
Encouraging integration and avoiding perverse incentives
Another potential trap for the national performance agencies is to focus tightly on performance measures for each type of health service, while neglecting continuity of care issues.
Workshop participants offered several proposals to avoid performance reporting echoing the silos of the health system.
First, performance measures could focus on improving the outcomes for people with chronic diseases such as diabetes, where good outcomes depend on effective working relationships across many health providers.
Second, the national agencies could explicitly measure how well health services are performing in providing integrated care and whether they are collaborating with other health services.
Finally, there was a heartfelt plea not to ignore the need to improve the performance of sometimes neglected areas including mental health services.
Participants warned against the obvious risk of performance measures resulting in perverse incentives – all the effort and resources being diverted to public hospital waiting time measures, with inadequate attention on other health services or population groups.
Promoting intelligent use of performance data
There was strong interest in ensuring that the national performance agencies added value to health services, rather than generating extra red tape and reporting burden. At the front-end, this included adherence to the ‘collect data once, use it multiple times’ approach.
Workshop participants also highlighted the benefits of effectively managed data linkage, the potential of the personally controlled electronic health record, and the need for national performance agencies to provide data back to health services that was clinically meaningful and could help generate a picture of population health needs for local planning.
Building a learning culture
The final set of issues and lessons relates to ensuring that health services (and governments) can learn and improve from the heightened focus on performance reporting.
One barrier is that the national performance agencies are generally prohibited from providing ‘policy advice’ on performance improvement: they can report poor performance, but are not allowed to offer advice to governments about systemic changes that might improve health service performance.
Creating a culture that encourages debate and promotes innovation is likely to be a continuing challenge for a health system, when the default position is to take a risk-averse approach and keep health system issues out of the media.
PS. Also a brief mention of the AHHA workshop in The Australian.