Performance measurement in the Swiss public hospital sector: towards successful promotion of performance-based accountability systems.

Vangelooven, Christa and Kunz, Stefan Juerg and Richter, Dirk and Hahn, Sabine (2014) Performance measurement in the Swiss public hospital sector: towards successful promotion of performance-based accountability systems. In: 10th Transatlantic Dialogue Conference Workshop 1 – Metrics and methods in collaborative settings of the EGPA (European Group of Public Management), 05.06.2014-07.06.2014, University of Lugano, Switzerland.

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Background Approximately one-third of public health care costs in OECD countries arise from the hospital sector. Public disclosure of hospital performance data therefore tends to be viewed as key to improving public health care spending efficiency. Furthermore, such data may also provide essential information for policy development, benchmarking, monitoring of quality improve-ment and patient safety issues. However, until recently, national comparative data on the quality of health care in Switzerland was scant. In 2011, ANQ (the National Association for Quality Development in Hospitals and Clinics) introduced the first annual National Point Prevalence Measurement (NPPM) of quality indicators for hospital acquired pressure ulcers (HAPU) and in-patient falls in Swiss acute care hospitals. ANQ consists of all important stakeholders in the Swiss health care system (e.g. gov-ernment, health insurances). Public disclosure of this data may contribute significantly towards the promotion of perfor-mance based accountability and efficiency in the public hospital sector. Yet, there is a risk that these expectations may not be met if the process is not managed properly. Since performance data should support the movement towards providing safer and improved care, this workshop does not merely aim at presenting the data on trends of the first national prevalence measures (2011-2012). It also intends to provide information on hospital usage of national quality data in Swiss hospitals and best practices regarding the dissemination of such data. Method For the NPPM, the International Prevalence Measurement of Care Problems method from Maastricht University was utilized. This instrument captures the outcome, structure and process indicators on institutional, ward and patient levels regarding falls and pressure ulcers. Transla-tion and cross-cultural adaptation into German, French and Italian was completed according to ISPOR Guidelines. The target population included all hospitalized patients 18 years of age and older. Data was analyzed utilizing descriptive and hierarchical logistic regression analysis (risk adjustment of outcome measures). Public disclosure of quality performance data is a relatively new topic in Switzerland. An on-line survey was developed to determine how Swiss hospitals currently manage this issue. This survey is conducted annually and it explores hospital usage of performance data in order to support internal and external benchmarking and quality improvement strategies. Results In 2011, 112 hospitals (representing 159 hospital sites, N = 10’606 patients, response rate 68%) and in 2012, 132 hospitals (representing 186 hospital sites, N= 13’651 patients, response rate 75 %) participated. Descriptive analysis revealed a total prevalence of HAPU degree 2-4 of 2.1% for 2011 and of 1.7% for 2012. In-patient fall prevalence was 4.3% in 2011 and 3.8% in 2012. National risk-adjusted outcome results revealed quite a homogeneous distribution among hos-pitals for both indicators. The confidence intervals (CI) of one hospital (2011 and 2012) differed significantly from the mean of all hospitals, indicating a higher HAPU rate degree 2-4. The CI of one hospital differed significantly for the in-patient fall indicator (2011 and 2012). Approximately one fourth of the participating hospital coordinators did participate in the ex-ploratory survey regarding hospital data usage. Results seem to indicate that hospitals with well-established quality improvement systems tend to focus on national benchmarking rather than on internal improvement strategies. Conclusion The prevalence measurement results provide, for the first time on a national scale, important health care quality information related to the quality indicators HAPU and in hospital fall events. According to the international literature, the results of the HAPU and hospital falls seem to indicate a good level of quality in Swiss hospitals. However, due to the mandatory procedure of obtaining written informed consent, the response rate of participating patients in the first measurement (2011) was quite low. This must be considered as an important limitation. The results may underestimate prevalence rates especially since severely ill and older patients (at risk) could not have participated in the measurement. Nevertheless, the results are useful in gaining insight into quality indicators such as pressure ulcers and falls at institutional and na-tional levels. Public disclosure of the results for both measurements has taken place in order to promote transparency of hospital performance for users (patients), society and stakeholders in healthcare (e.g. in decision making). As discussed above, adequate management of public disclosure of this data is crucial for a successful promotion of performance based accountability systems. In this context, the use and dissemination of quality data is discussed along with the importance of strategies such as user, practitioner and stakeholder involvement.

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