Integrated Performance and Incentive Framework: Achieving the Best Health Care Performance for New Zealand The health sector needs a new performance framework because: There is widespread support for a broader framework for thinking about health system performance which enables better patient centred services; The overall direction of the health system is towards increased integration and collaborative decision making across the range of community and hospital services, and this should be reflected in measures of performance; There is no existing performance framework for primary health care which acknowledges and builds upon the wider motivations of professionalism and influence upon services, as well as financial incentive for individual practitioners. There are several existing frameworks for performance in different parts of the health sector, such as the DHB Accountability Framework, the PHO Performance Programme and various other performance and accountability frameworks each of which are not strategically aligned with each other resulting in fragmented focus and effort; Intent of the framework 1. The Framework will incorporate the use of Health Targets and Better Public Services i goals across the health sector, and will promote the government goal of improved service integration; 2. The Framework will align core health and disability sector reporting and monitoring frameworks such as the DHB accountability measures, and will reduce rather than add to the burden of reporting; 3. The Framework will embed the responsibility of clinicians to the patients of today and to the patients of tomorrow; 4. The Framework will recognise Triple Aim goals as the organising principle of measures, and will provide a line of sight which makes explicit the contribution of organisations to key system level performance measures across the dimensions of: improved quality, safety and experience of care; improved health and equity for all populations; and best value for public health system resources; 5. The Framework will initially apply to general practice, Primary Health Organisations and DHBs. It will be designed so that over time it can scale to encompass a wider range of services across the health and disability system, including maternity services; 6. The framework will have the potential to address performance on broader health, disability and social indicators, as well as traditional core health and disability services; 7. The framework will enable monitoring of performance in addressing Maori health needs; 8. The Framework will identify low performing organisations and be a vehicle for supporting them to attain at least minimum standards of acceptable service, but it will not accept persistent non-performance; 9. Performance will be transparent to peer organisations and to the public; 10. The Framework will provide an incentive to practitioners and organisations to improve levels of performance over time, with excellent performance ultimately becoming common across the health and disability system; 11. The Framework will have the flexibility to allow its evolution over time; 12. To support the development of alliances to make early and significant progress in health service integration; 13. To provide incentives that are relevant to graduated levels of performance from entry level to breakthrough innovation; 14. Conditions of access to referred services may be made more flexible and linked to demonstrated performance.
How it could work Balance between individual and joint accountability for performance across the health system The framework should be founded in the Health Quality and Safety Commission triple aim, based around a small number of high level national system measures from triple aim domains, reflecting the overall performance of the health system. System level measures should apply equally to all districts and all groups within a district, and will be subject to a target or benchmark against which performance of the whole system within a district can be assessed. A small set of system level measures should be set by the national governance body. Under each system level measure there could be a range of contributory measures, which reflect the particular activity and role of different organisations and professionals, and how they support the system level measure. Contributory measures could be chosen locally from a broad menu, reflecting local priorities for performance improvement, and should align with the areas of activity identified in each district s Quality Accounts, currently developed by DHBs and reported to HQSC. These measures should be chosen within the alliance framework being implemented with PHOs and DHBs. Performance against contributory measures would be used for quality improvement and comparison within districts, and will need to be supported by effective clinical governance and quality improvement processes. While individual organisations within a district can be seen to achieve separately at a high or low level, progression across the levels from Improvement, to Excellence to Breakthrough should apply to a district as a whole, and be based upon consistently high performance across practices, PHOs and DHB together, rather than any one component of the system in isolation. Using resources and influence to support professional practice and patient centred decision making There are a number of options for the use of performance funding attached to the framework, one of which could be to use this financial resource to greater support clinical governance and quality improvement, contributing to local determination of performance improvement priorities, and supporting clinical programmes to improve performance. Clinical governance activities and approaches should be agreed with and reported upon to a local alliance and shared between districts. The effect of the joint and individual elements of the framework would be to reveal system wide performance of a district. At the same time it will make clear where there are strengths and weaknesses in the individual elements of the health system within a district, whether at DHB, PHO or practice level. Organisations with a demonstrably higher level of performance will be in a position to exercise leadership and influence within a district, building upon their demonstrated expertise and achievement to assist others in the district to improve their performance. Acknowledging a range of performance from minimum standards, through performance improvement, to exceptional achievement, with innovation at every level The framework would set minimum standards for participating in health service provision, would assess performance and quality improvement from minimum standards to a level of excellence, and would provide for high performing districts to be able to negotiate for reduced constraints upon service development, in order to promote further innovation. Sector wide clinically led governance of the framework making transparent, best practice based decisions about performance measurement The framework would need to be governed by a group with sector wide representation, and strong clinical leadership. This should make decisions about the ongoing development of the framework structure, evolution of particular measures, and the application of the framework to health organisations. It is key that the governance of the framework be seen to be professionally credible, and independent of particular interest groups. The accountability of DHBs under the Crown Funding Agreements will need to be respected, while DHBs will be incentivised to implement the framework successfully.
Example: relationship between system and contributory measures For a given system level measure it becomes the responsibility of the players within the district, through their alliance, to identify suitable contributory measures for different services. This will depend upon local analysis and understanding of the issues underlying the system measure within the particular district, and reflect an expert local understanding of where performance needs to improve in order to increase performance at the system level. So if, for example, the system level measure bears upon reducing adverse events, contributory measures might include: Activity around medication management in pharmacy and general practice; Activity around falls prevention in both community and hospital; Reduced pressure injuries in hospital; Reduced hospital acquired infections. This means that while the system performance as a whole is judged upon the system level measure of adverse events, the network of contributory indicators can support the necessary quality improvement programme needed to achieve gains for the system overall, and can reveal variation in achievement across the range of health services within a district. This combines a performance approach, based upon the principle that a system can only be judged to be good if the whole system is performing well, with a quality improvement approach in which general practice, pharmacy, hospital and other services focus their efforts upon the quality activities relevant for them. Structure The schematic diagram below sets out the structure of the proposed framework, with both system level and contributory measures at each level.
In order for the framework to be effective in enabling change, alignment will have to be achieved over time between existing DHB accountability frameworks and the structure and measures proposed here. This will build upon the current policy direction to encourage DHBs to take a system wide approach to working with their primary care partners. Similarly, there would be value in alignment between the areas of activity covered in DHB Quality Accounts and the contributory measures of the framework. These areas of alignment will help to minimise duplication of effort and reporting burden, while ensuring that the framework will achieve the greatest possible value from existing mechanisms within the sector. Incentives and mechanisms for performance improvement The proposed framework would not rely upon direct financial incentives for performance improvement, although there are some financial incentives as discussed below. This reflects: Support for the basic values of professionalism and community service which underpin the motivation of health professionals and health service organisations; Acknowledgement that incentives at general practice level can be affected by the internal business model of practices within PHOs, which are beyond the control of a performance framework; A desire to learn from international experience and avoid the problems of excessively highly financially geared output measures in the framework; Limited direct funding available for incentives, that will be spent so as to get a balance between capacity building and incentives for results. Incentive funding will generally cascade down to the front line service providers; The proposed framework envisages using existing performance programme resource for the purpose of supporting effective clinical governance and quality improvement programmes across both primary and secondary care sectors. The framework provides incentives for performance improvement by means of: Influence: The framework will make clear where organisations within a district are performing at a high level. Within the context of a district alliance, this will enable influence in determining the direction of service development, and what priorities for service development should be. Where there is variation in performance within a district, joint accountability will provide some support for organisations to take joint responsibility for working to address issues across the system. For example, where primary care is demonstrating high performance on contributory indicators, it will be in a strong position within the alliance framework to influence the decisions on use of service resources for further performance improvement; Freedom to exercise professional judgement: The framework envisages innovation at all levels, and will adopt a tight loose tight approach, allowing specification of desired results and resources, but a high level of freedom in how professionals work to achieve results. As district health systems move up the framework, it is envisaged that higher levels of performance will see less national determination of measures, and more local determination of strategic planning priorities and the corresponding measures on which performance is assessed. However, high level performance indicators will always be
nationally determined. Under this framework greater professional freedom will be promoted by encouraging local determination of contributory measures, and building upon local quality improvement initiatives, rather than imposing external quality improvement programmes. Supporting strong clinical governance: Using resources for performance improvement to require strong clinical governance mechanisms within districts which provide a mechanism to strengthen local clinical practice in a way led by professional values and using peer review systems. As well as positive incentives, the framework has some potential to address barriers to performance improvement. In some cases there are other relevant policy settings or system mechanisms which also require development in order to address key barriers. These are analysed in the table below:
Barrier Comment Impact Potential of the framework to address barrier System rules Impedes professional ability to Appropriately set measures which exercise clinical judgment, and can have the potential to reveal inappropriately result in delays or duplication in constraints upon clinical constrain clinical accessing an appropriate service practice. practice Division over resources Capability and expertise Access to information Ability to prescribe or refer, or to access specialist opinion rapidly. Constraints often driven by desire to manage resources closely. Organisations and professions compete for local resource. Leadership and analytical ability to analyse local and national information, and develop effective local programmes of service development. Constrains ability to analyse service challenges, and to provide detailed service information to clinicians. Increases local focus upon the issue of who has control over resources, rather than a collaborative consensus on the best use of resources. For example, district nursing services - controlled by DHB planning and funding or by primary care organisations. Impedes ability to analyse local problems, to transfer solutions from other contexts, and to build consensus about preferred local direction. National datasets are not generally accessible, meaning that robust national benchmarking is difficult and patchy in the execution. Local primary care data is fragmented, and managed within a context of commercially closed practice management systems. Addressing specific constraints (eg access to radiology referral) can be included as capacity performance measures Can increase district level focus on achieving outcomes, rather than debating resource control and power issues; Can link the performance of individual organisations to the best community level outcome. Has the potential to reveal capacity gaps. Has the potential to monitor capability and identify areas of good practice and areas of weakness nationally. A performance framework can potentially be a catalyst for requiring better information flows, both locally and nationally. Improved data standardisation and comprehensive definitions. Other Policy Settings National expectations about removing inappropriate constraints upon practice are increasingly being set in expectations for DHBs, the most topical issue currently being access to radiology. While a national policy setting can require primary care referral access to specific interventions or modalities, there are still local effects (e.g. limited capacity resulting in lengthy waiting times for community radiology referral). Alliances as a vehicle to manage resources collaboratively. Investment in and development of effective service development capacity. More open access to information needed to monitor and improve performance, including access to national datasets, and better direction on primary care data management and access.
Governance There are several governance functions that will need to be factored into the design of the framework as follows: National level governance At a national level there will need to be strong clinical leadership and governance over the evolution of the design of the framework, to retain and adapt where necessary its strategic intent and to incorporate an increasing range of health and disability services. This governance function should also ensure that over time the framework will align the existing and planned range of organisational quality, performance and accountability arrangements. The system level measures, thresholds, range and attribution of incentives will also need to be reviewed and determined at regular intervals. The national governance body could also fill the function of arbitrator, should the need arise, where there are local level disputes over performance and associated consequences. The activities of the national governance body and the accountability of DHBs under the Crown Funding Agreements will be aligned. Both government and sector priorities will need to be reflected through the governance of the framework with an inclusive and transparent model of decision making. To be effective at this level the strategic governance would need to ensure it has mandated government representation and credible national participation from consumers and the range of clinical and professional groups that are party to the framework. In effect, the strategic governance function should follow the form of a national alliance, with members chosen for their relevant knowledge and recognised credibility in the area. Membership of the governance group should be independent and transparent, following an open advertisement and appointment process such as that used to appoint members to Pharmac s therapeutic advisory committee. District level mechanisms The framework would require the participants in district level health systems to work together to set strategic priorities, to establish the local elements of system and contributory measures which will underpin those priorities, and to implement quality improvement mechanisms across the different services covered by the framework. This essentially builds upon the task already placed before district level alliances, and requires that well functioning alliances should establish local system level and contributory measures which are well founded in their planning processes, which have the buy in of local clinical leaders, and which are linked to effective local clinical governance processes. DHBs, PHOs and general practices (in the first instance) would therefore need to work within their alliances to agree on local level contributory measures for their relevant organisation at the district level, and through planning cycles and within nationally agreed parameters, regularly review and reset these measures and thresholds. As the district level system would only be able to progress through the tiers of performance in the framework as a whole system, the relevant parties within that district will need to determine their own performance improvement plan and how they will invest financial incentives and attribute non-financial rewards. This should be done with the support of the national governance group, but essentially the local district alliance arrangements will be the lynchpin for making progress at the local level.
Measures The basic approach for choosing measures within this framework is: 1. The use of the NZ adaptation of the Triple Aim; 2. Within each dimension of the Triple Aim, there will be a small number of system-level indicators that have thresholds applied and will be reported upon nationally; 3. Health systems which are operating at a higher level of performance will have fewer requirements for national consistency, and more ability to choose measures which reflect local strategic priorities; 4. There will be a broader set of contributory measures that have clear causal linkages with the relevant system level measures; 5. The contributory measures do not necessarily require targets and provide a level of local (District) autonomy in terms of what measures are used; 6. Ministerial Health Targets will be included in the measures; 7. The model should not increase the reporting burden on the sector. Measurement frameworks have the potential, if they are badly developed or implemented, to cause harm or to distort health services. The inherent difficulty of measuring outcomes in activities such as health care, where there are complex causal relationships between inputs, outputs and outcome measures, mean that it is sometimes easy to fall into the trap of focussing upon the easily measurable rather than the important. It is important that focussing upon measurable aspects of health services does not crowd out professionally motivated health care. The task of choosing indicators and setting thresholds for assessing performance is therefore key to the overall framework. Much depends upon the specific indicators which are chosen, and the balance between national consistency and local determination. Targets for performance attached to particular indicators should be set so as to achieve a balance between making performance improvement realistically achievable, and representing a genuine challenge to achieve improvement. If targets are too stringent and unrealistic, there is a risk that they will demotivate participants, and that a small lapse on a single measure will have a disproportionate impact upon the reputation of the whole system. But conversely, targets should also represent genuine aspiration for improvement, rather than statically maintaining historical levels of performance. This balance will be a major element of the ongoing task of the framework governance group, which will have to ensure that measures and targets are appropriately set, clinically meaningful and adjusted accordingly over time. Health service consumer perspective From the point of view of a consumer, the key elements of the framework are: The overall level of performance of a local health system will be clear, and consumers will be able to see how their local system compares to others across New Zealand; System performance will be transparent, and consumers will be able to make choices or exert public pressure upon PHO performance; Consumer experience measures will, in time be included in the framework, making responsiveness to consumers a direct measure within the framework; A consumer perspective will be included in the governance.
Taxpayer perspective From the point of view of a taxpayer, the key elements of the framework are: The triple aim requires a constant focus upon providing better care to more people for the money government allocates to health; The framework will promote more cost-effective use of resources across the health system; Measures have the potential to focus upon reducing wasteful variation Professional perspective From the point of view of a health professional, the key elements of the framework are: There are minimum standards for service provision, set in collaboration with professional bodies that may be made visible and applied through the framework; There is potentially direct support for clinical governance, providing access to continuing professional development and best practice clinical education programmes; Where a professional works within an organisation which is achieving a high level of performance, they will have an increased influence over service development and priorities for changing services, through and within the context of an alliance. Improved access to referred services on a performance related basis. PHO Perspective From the point of view of a PHO, the key elements of the framework are: There is opportunity as part of the governing alliance to input into the selection of the contributory indicators in order to reflect local and community priorities for service and performance improvement; There is joint accountability for system level indicators in a district. Where individual PHOs are holding back the performance of a whole system, other PHOs and the DHB will need to work with them in order to address the reasons for lower performance, and to share expertise and approaches for performance improvement; High levels of performance can be publically visible, giving recognition and reputational strength to high performing PHOs. There is the potential for investment in capacity building for clinical governance. DHB perspective From the point of view of a DHB, the key elements of the framework are: The DHB s district level accountability for the system is explicit, but is also shared with other parties within the framework; Existing framework and the DHB accountability mechanisms will need to be aligned over time; There is choice of relevant local contributory measures for the DHB s component of service provision; The framework operates within an alliance structure, requiring collaborative relationships between DHBs and other parties within a district; High levels of performance will be publically visible, and have the potential to be translated into streamlined and flexible accountability arrangements. i http://www.ssc.govt.nz/better-public-services