Performance Management and Accountability

Performance management is the use of measurement to monitor and improve how well a health organization achieves its goals, while accountability is the obligation to answer for that performance to patients, payers, regulators, and the public. Together they translate broad aims for quality, safety, and value into indicators that can be tracked and acted upon.

Definition

Performance management and accountability refers to the use of defined indicators and measurement systems to assess how well a health organization meets its objectives, together with the arrangements through which the organization is held answerable for that performance.

Scope

This topic covers quality indicators and performance measures, the conceptual basis for measuring care quality, the mechanisms of accountability such as accreditation and public reporting, and the limits and unintended effects of measurement. It is a reference treatment of how organizational performance is assessed and is not guidance on setting targets for any specific organization.

Core questions

• How is the quality of care measured?
• What is a quality indicator and what does it capture?
• Through what mechanisms are health organizations held accountable?
• What are the limits and unintended effects of performance measurement?

Key concepts

• Quality indicators
• Structure, process, and outcome measures
• Accountability mechanisms
• Accreditation
• Public reporting
• The Triple Aim and value
• Unintended effects of measurement

Key theories

Structure-process-outcome framework

Donabedian proposed that the quality of care can be assessed through three linked categories — the structure in which care is given, the processes of care delivered, and the outcomes achieved — which remains the dominant conceptual basis for selecting quality indicators.

Mechanisms

Performance management works by defining indicators that operationalise an organization's goals, collecting data against them, comparing results to benchmarks or targets, and feeding the findings back to drive improvement. Donabedian's structure-process-outcome triad provides the conceptual scaffold for choosing what to measure. Accountability is exercised through internal review and through external mechanisms such as accreditation, regulation, and public reporting, which create pressure and incentives to perform. Because measurement focuses attention and can be tied to incentives, it can also distort behaviour toward what is measured, so indicator design and interpretation require care.

Clinical relevance

Performance and quality indicators describe how well care is being delivered across an organization or system and inform accountability and improvement. They characterise aggregate organizational performance and are not a basis for any individual patient's diagnosis or treatment.

Evidence & guidelines

Evidence on performance and quality measurement spans conceptual and empirical work. Donabedian's framework underpins indicator selection; McGlynn and colleagues' study documented large gaps between recommended and delivered care, motivating systematic measurement; Berwick and colleagues' Triple Aim frames performance in terms of care, health, and cost; and studies of accreditation, such as Pomey and colleagues', examine how external review functions as an accountability and change mechanism.

History

Systematic measurement of care quality grew from Donabedian's mid-twentieth-century framework into a large enterprise of indicators, accreditation, and public reporting as payers and regulators sought accountability and value. Documentation of wide variation and shortfalls in delivered care, notably by McGlynn and colleagues in 2003, intensified demand for measurement and transparency.

Debates

Does performance measurement improve care or distort it?

Measurement focuses attention and can drive improvement, but it can also produce gaming, tunnel vision, and effort diverted to what is counted; the balance between accountability and unintended distortion is a continuing concern in indicator design.

Does accreditation reliably improve organizational performance?

Accreditation is widely used as an accountability mechanism and is argued to drive organizational change, but evidence on whether it consistently improves outcomes is mixed, leaving its value as a lever contested.

Key figures

• Avedis Donabedian
• Elizabeth McGlynn
• Donald Berwick
• Marie-Pascale Pomey

Seminal works

• donabedian-1988
• mcglynn-2003
• berwick-2008

Frequently asked questions

What are structure, process, and outcome measures?

They are the three categories of Donabedian's framework: structure refers to the attributes of the setting in which care is given, process to what is actually done in giving and receiving care, and outcome to the effects of care on health status.

Why can performance measurement have unintended effects?

Because measurement focuses attention and is often tied to incentives, it can encourage organizations to optimise what is measured at the expense of unmeasured aspects of care, a risk that careful indicator design seeks to limit.