Promoting health care quality: what role performance indicators?

"Quality" is the big issue which is currently fashionable in healthcare circles in several industrialised countries. In the United Kingdom the government's White paper on the National Health Service (NHS) and subsequent documents stress that "the new NHS will have quality at its heart"1 and that "high quality care should be a right for every patient".2 In the United States, a Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry has recently called for a national effort to improve and sustain the quality of health care.3 Healthcare purchasers have been demanding, adopting, or developing measures of healthcare performance, and in the United States several national organisations-such as the National Committee for Quality Assurance (NCQA), the Foundation for Accountability (FACCT) and the Joint Commission on Accreditation of Healthcare Organisations (JACHO), have been developing quality metrics. There has been an explosion in the development of performance indicators of variable provenance and quality, some of which are on the JACHO's national library of healthcare indicators. Developing, collecting, analysing, and feeding back performance data from healthcare organisations is now big business. In the United Kingdom similar developments are occurring but at a much slower rate reflecting differences in the organisation and financing of health care, the relative lack of routine data, poorly developed information systems, and cultural factors. The recent proposal by the Department of Health in England to establish a framework for assessing performance (measuring aspects of health improvement, fair access, effective delivery of appropriate care, efficiency, the patient experience, and health outcomes) as opposed to simply counting "beans" and relying on the largely discredited "efficiency index"4 is a welcome and bold step.5 There is a danger, however, that these efforts will not result in the anticipated gains in quality because of potential conceptual and technical weaknesses in the performance management agenda. This paper discusses some of the issues raised by the use of performance indicators in managing healthcare services. The tone is cautionary in the context of the rapid investment in and relatively unevaluated adoption of performance indicators as one of the key elements of quality improvement strategies, whether the approach used is one or more of regulation, competition, continuous quality improvement, or financial incentives.