Part A

1.0 Introduction

Historically, the quality of health care has largely been determined through the professional judgement of individual clinicians. However, with rising health care costs and limited funds, governments world wide are seeking objective evidence that health care services are provided effectively and efficiently, whilst maintaining and enhancing the quality of patient care.

Performance indicators are powerful tools by which the quality and effectiveness of health care can be monitored, assessed and improved. They provide quantitative information to enable consumers to make informed choices about treatment options; for providers to know the level at which they are practising; and for purchasers and funders to make appropriate policy and purchasing decisions.

Much work has evolved in recent years in developing and implementing appropriate performance indicators for use within acute health sectors, both within Australia and internationally. The identification of indicators which are useful for all Victorian stakeholders, for both internal quality improvement and external accountability, requires a carefully considered strategy. This paper will therefore:

2.0 Background

The Department of Human Services has over a number of years provided significant support for performance indicator initiatives.

In 1992, funding was granted by the Department to the ACHS Care Evaluation Program to establish a model program for the implementation of clinical indicators within two metropolitan hospitals. The twelve month project focused upon the implementation of the Hospital Wide Medical Indicators 1, being the first set of performance indicators developed by the ACHS in co-operation with the Royal Australian College of Medial Administrators. Additional funding was provided in 1995 to extend this process to a further twelve Victorian hospitals based upon use of the earlier produced publication, A Working Guide for the Implementation of a Clinical Indicator Program2, within various hospital settings.

A number of indicators were introduced for monitoring the performance and quality of Victorian public acute hospitals with the introduction of casemix funding in 1993, including that for unplanned readmissions and more recently indicators relating to access and efficiency. However development has been ad hoc and not in the context of an overall and planned framework.

In 1995, a review of the quality of care in Victorian public hospitals was undertaken and reported by the Health and Community Services Committee on Quality, A New Framework for Quality in Victoria's Public Hospitals3. A number of key recommendations were made by the Committee, to both ensure and promote the quality and effectiveness of health care delivery, including, that:

The Department develop a standard information set for quality assessment to ensure consistency of information across the hospital system.

In October 1996, the current Acute Health Quality Committee (AHQC) was established under the leadership of Professor Stephen Duckett. In light of the above recommendations, there was agreement at the inaugural meeting in November 1996, that the identification and development of performance indicators should be a significant activity of the Quality Committee. This position has been endorsed at subsequent meetings, whereby it was agreed that a performance indicator framework would be developed which is:

This process is now in place and staff employed to advance the work. A preliminary work plan was developed and endorsed by the AHQC in May 1997. (Appendix 1). This discussion paper completes Phase 1 of the strategy as per the work plan.

Current Status of Indicator Development

A review of existing indicator programs across a variety of levels within Australia and overseas, can inform the development and implementation of indicators within the Victorian context.

3.0 State Programs

Performance indicators are in use by Health Departments across all Australian States and Territories to varying degrees. State programs have tended to rely upon existing indicators in common usage, and in particular the ACHS Clinical Indicators. Definitions in some instances have been modified, to enable data collection via routine existing data sources, thus comparability between states is not feasible. Detail pertaining to Victoria and an overview of indicator programs in other states is provided.

3.1 Victoria

3.1.1 Access indicators

Indicators have been developed and are in use in several key areas. Of particular note are indicators of access. Elective waiting list data are collected from 27 hospitals and represent approximately 80% of elective admissions in Victoria. Data are also collated from 26 hospitals which participate in the Victorian Emergency Minimum Dataset (VEMD), which provides detailed information relating to emergency services and enables the Emergency Services Enhancement Program. Indicators which monitor access to Critical Care Beds (Intensive Care and Coronary Care) are also in place and work is continuing with a working group of Intensivists to further develop indicators for Intensive/Critical Care areas. Access indicators which are currently being monitored are listed below and are reported in aggregate and per (participating) hospital in the quarterly Hospitals Services Report4.

3.1.2 Report Cards

Agreement has been reached with the Metropolitan Healthcare Networks for the development and use of a set of performance indicators to be reported as a "Report Card" as from July 1997 (Appendix 2). The proposed indicators relate to efficiency/productivity, access (as above), financial measures (not reported here) and quality measures.

Efficiency/productivity indicators include:

A number of quality indicators have been proposed as listed below, however pending further work in this area, none have been included in the report cards at this stage. Other proposed indicators include:

3.1.3 Other Potential Indicators

Several acute health quality programs and initiatives are in progress which will be reported to the AHQC. These include: . Each of these areas lend themselves to future performance indicator development as a part of the overall Department indicator strategy.

Work has also been proceeding within the Public Health Division in modelling mortality and morbidity data for specific (high throughput) conditions, such as prostatectomy and cholecystectomy and may lend themselves to indicator development. Work has been undertaken and reported by the Public Health Division on the use of E codes (external causes of injury) for the detection of adverse events through retrospective analysis of VIMD data5. Whilst the limitations of this extraction system are recognised, it should not be discounted for the purposes of the indicator strategy.

3.2 New South Wales

In December 1995, The NSW Department of Health's Clinical Indicator Steering Group recommended the development and evaluation of a set of quality of care indicators for routine quality monitoring and peer comparison. Negotiated performance contracts between the Department and Area Health Services identified the priority areas of access, efficiency and quality of patient care. To date, no quality of care indicators have been specified in the contracts, mainly due to concerns pertaining to data reliability and validity 6.

The Department encourages external accreditation and has been reviewing the utility of ACHS Clinical Indicators (unplanned readmissions and return to operating room). It also has an extensive program for the identification of indicators for nosocomial infection, relating to bloodstream infection, multi resistance organisms, paediatric nosocomial infections and surgical site infections. Specific indicators are to be piloted by a core group of pilot hospitals7. Another initiative is the Priority Access Strategy which is likely to adopt access indicators for elective admissions and attendance at Emergency Departments.

In developing and using performance indicators, the NSW Department seeks to ensure that nominated indicators will meet various internal and external reporting demands and recognises the need to develop systems to support collection and monitoring activities6.

3.3 Other States and Territories

A number of indicators are being monitored through the Casemix and Clinical Costings Unit of the South Australian Health Commission. Some of these have been adapted from the ACHS indicators, including emergency readmissions, returns to operating theatre and nosocomial infections. Others include health status assessment (SF 36), patient satisfaction, facilities accredited and indicators relating to access, and efficiency.

Tasmanian Health Service Agreements require hospitals to demonstrate quality of services by regularly reporting against a range of clinical and performance measures. These include indicators adapted from the ACHS Hospital Wide Medical Indicators, readmission rates, elective surgery waiting times, outpatient activity, emergency department waiting times, cost and efficiency indicators and clinical research and teaching. Work is also proceeding to develop systems for statewide patient satisfaction and complaints reporting.

The Health Department of Western Australia established a working group to consider indicator monitoring and a number of indicators were recommended, although these are not currently being collected at the individual hospital level.

The Australian Capital Territory has performance indicators included in all purchaser-provider contracts which are reported at various intervals. The indicators in use relate to elective surgery waiting lists, theatre utilisation, emergency and outpatient waiting times, accreditation status, patient complaints and satisfaction, as well as cost and volume measures.

Within the Northern Territory, consideration is being given to performance indicator use and standardisation of information systems within health and hospital areas. Priority issues relate to access to care, remote health services and referral patterns.

There are no known state-wide programs in place in Queensland.

4.0 National Programs

4.1 ACHS Care Evaluation Program

The ACHS Care Evaluation Program (CEP) has received Commonwealth funding since 1989 for the establishment of medical clinical indicators together with Australian medical colleges. A list of the indicator sets is incorporated at Appendix 3. The ACHS has led the way both nationally and internationally in the development and introduction of indicators into a national accreditation program as a mechanism to monitor and evaluate the quality of clinical care.

Indicators have/are being developed in 19 various clinical areas (hospital wide and discipline specific). As of 1997, twelve sets are available for use and the remainder are expected to be released during 19988. Organisations which participate in the ACHS Evaluation and Quality Improvement Program (EQuIP) submit quantitative and qualitative clinical indicator data to the CEP twice yearly, for inclusion into a National Aggregate Database. There is no mandatory requirement for organisations to address specific numbers or types of indicators; more importantly, organisations are encouraged to monitor those that are useful and relevant to their service delivery. Indicator results are aggregated and reported annually in a National Aggregate Report, Measurement of Care in Australian Hospitals 9 and by organisation specific reports that provide comparisons based on a number of variables, including hospital type and size, to like or peer hospitals. During 1996, additional data elements were collected to allow for further stratification, relating to average casemix weight (where applicable) and relevant discipline specific variables.

A major achievement of the CEP had been the participation of the medical profession in the development and implementation of indicators. This was a primary objective of the program. The focus of the program has been using the indicators within quality programs for internal evaluation and promoting improvement in patient care through action and practice change. The indicators generally serve this purpose well, however, their application as external accountability measures is less certain, given the inability to extract much of the required data from routine data sets and lack of risk adjustment at patient level. The ACHS does not currently have access to patient specific details and thus relies upon hospital characteristics as a simpler alternative and as a surrogate for casemix adjustment.

The indicators have also been criticised as lacking reliability and validity as determinants of quality. However, all indicators are identified and defined by experts in the field (face validity) and definitions and utility are established through national field testing (content validity). Based upon quantitative and qualitative data accumulated over twelve months, indicator sets are reviewed and refined by college working parties to ensure their applicability and relevance to the field.

Despite some limitations, the ACHS indicators have been fundamental in advancing the development and use of performance indicators in Australia and continue to serve a valid function in terms of quality improvement initiatives. Preliminary work has also been undertaken by the CEP to establish criteria and define a core set of indicators from over 250 that are now in development and/or use, however, no definitive policy has yet been developed by the ACHS.

4.2 Commonwealth Initiatives

The Commonwealth Department of Health and Family Services (CDHFS) has a strong interest in developing and implementing quality and outcome indicators for the acute health care sector. This commitment is in keeping with the broad reform agenda of the Council of Australian Governments (COAG). A strong focus of the COAG meetings has been toward improving the quality of health care and the need for outcome based performance indicators and funding mechanisms with incentives for demonstrated quality of care.

4.2.1 Health Service Standards Report

A number of programs and initiatives, emanating largely from the Health Service Outcomes Branch of the CDHFS, are in place to develop and assess performance indicators. As part of this process the Commonwealth is committed to the reporting and publication of performance information, as per the goals of the National Health Policy, to improve accountability, enhance service delivery and enable consumers to make informed choices.

A Health Service Standards Report (HSSR) for consumers is currently in development, to provide comparative information about the performance of hospitals. Following extensive consultation by the Consumers Health Forum, it emerged that there was strong support for the notion of a performance report as a way of driving hospital reform and improving quality. The first draft of the report is due for release in 1998 10.

4.2.2 National Health Ministers Benchmarking Working Group (NHMBWG)

In early 1996, the NHMBWG, under the auspices of COAG, released a report, The First National Report on Health Sector Performance Indicators. This depicted a set of performance indicators for the health sector and brought together data for the purposes of reporting against the indicators11. The indicators were developed in a framework directed towards the measurement of system wide performance and to stimulate benchmarking and incentives for continuous improvement (Appendix 4). Release of the report was considered to mark the introduction of performance based funding (outputs and outcomes) under the COAG reforms12.

The indicators which are summarised in Table 1 relate to the areas of efficiency, productivity, quality and access and have been proposed largely in light of current national collection mechanisms.

Table 1: Summary of Hospital Performance Indicators (NHMBWG)

Category Indicator
Efficiency Cost per casemix-adjusted separation
Cost of treatment per outpatient
Average length of stay for top twenty AN-DRGs
Productivity User cost of capital per casemix-adjusted separation
Ratio of depreciated replacement value to total replacement value
Total replacement value per casemix-adjusted separation
Labour costs per casemix-adjusted separation
Quality Rate of emergency patient readmission within 28 days of separation
Rate of hospital acquired infection
Rate of unplanned return to theatre
Patient satisfaction
Proportion of beds accredited by Australian
Council on Healthcare Standards
Access Waiting times for elective surgery
Accident and emergency waiting times
Outpatient waiting times
Variation in intervention rates
Separations per 1,000 population
Source: Report of NHMBWG, 1996.

4.2.3 Taskforce on Quality in Australian Health Care

In light of emerging developments in Australia, the Taskforce on Quality in Australian Health Care considered the use of performance indicators to monitor the safety and quality of patient care. In the final report of June 1996, the Taskforce recommended that reliable and valid indicators be routinely used and that definitions and approaches to measurement be agreed at the national level to allow for comparability13. The Taskforce also recommended that:

4.2.4 Pilot Hospital Wide Clinical Indicators Project

Given the emphasis on the reliability and validity of performance indicators, particularly if used as measures of external accountability and for inter-hospital comparison, the Commonwealth funded a major project in 1995 to determine the reliability and validity of four quality of care indicators and to determine possible models of risk adjustment. The project work was undertaken by the Monash University Department of Epidemiology and Preventive Medicine in cooperation with the Alfred Healthcare Group. Four indicators adapted from the ACHS Hospital Wide Medical Indicators1 were studied, relating to: The project attempted to derive reliable indicator data from administrative datasets across three states, (Victoria, New South Wales and South Australia), evaluate the data capture mechanisms and conduct case control validity studies to determine possible relationships to quality of care. The final project report is shortly to be released. In essence it was concluded that there is poor reliability of data when obtained through administrative databases and that it was not feasible to clearly differentiate between good hospital care and poor hospital care. Hence, the indicators were considered insufficiently robust to be used for external accountability and comparisons. However, they may still be useful at the local or internal level for quality improvement purposes14.

4.2.5 Quality and Outcome Indicators Project (QOIP)

Another major project commissioned by the CDHFS through the National Hospitals Outcome Program was the Quality and Outcome Indicators for Acute Health Care Services Project, which aimed to: The final project report was released March 1997 and is already informing the development of a consistent set of quality and outcome indicators at the national level15.

Eight dimensions of quality of care were identified as the basis for indicator development which builds on the framework proposed by the NHMBWG. These are:

Further to this, ten indicator attributes were identified as the basis for assessing and deciding upon the potential utility of nationally consistent indicators. These will be discussed later in this paper.

The project team recommended that national indicators be developed as a core set for long-term and continuous collection, together with indicator modules for periodic collection. The core indicators should focus upon aspects of care common across conditions and be based upon data from administrative databases and surveys. The modules are to be targeted to specific conditions, diseases, diagnoses and interventions in keeping with national health priority areas and include hybrid data collection mechanisms. Those under consideration include coronary artery bypass graft, acute myocardial infarction, asthma care and childbirth.

Indicators which have been suggested for trialing for national usage, based upon their soundness, feasibility of data collection and utility of indicators, are summarised in Table 2. Those considered appropriate as core indicators are marked with an asterisk *.

Table 2: Indicators Recommended for Trialing as a National Set

Category Indicator
Access Elective surgery waiting times.*
Emergency department waiting times.*
Waiting times in emergency department prior to emergency admission.*
Patient based reports of elective surgery, emergency and outpatient department waiting times and acceptability of these times to patients.*
Efficiency Cost per casemix adjusted separation*
Safety Adherence to best practice guidelines
Observed to expected outcome ratios
Effectiveness Generic health status (SF36 or 12).*
Condition specific health status/quality of life measures
Stratified mortality rates
Unplanned readmission rates (asthma)
Low/very low birthweight rates (obstetric care).
Continuity Patient based assessments using relevant modules from the Picker Commonwealth survey instrument.*
Acceptability National survey based upon components of Picker Commonwealth, Hospital Corporation America and Royal College of Surgeons instruments.*
Technical Proficiency Risk adjusted technical proficiency measures
Appropriateness Relative utilisation rates of targeted procedures.*
Include-cardiac catheterisation, CABG, angioplasty (PTCA), cholecystectomy, hysterectomy, laminectomy, caesarean section, vaginal birth after caesarean section, prostatectomy
* Core Indicators
Source: Quality & Outcome Indicators 1996

Following release of the report, the Commonwealth responded with a collaborative workshop for stakeholders to further progress indicator development by way of five expert groups10,16,relating to:

A consultancy was subsequently commissioned to review and advise on access indicators for elective surgery, emergency and outpatient departments at the national level. This work has been completed and reported to the Commonwealth, however, it is still under consideration by the Department17.

A pilot study is shortly to be commissioned to review utilisation rates for hysterectomy and related conditions. Work relating to condition specific modules is also being considered by a working group relating to cardiovascular disease and stroke. Consumer focused indicators are being considered in light of the work of the National Consumer Collaboration. The Commonwealth Government has allocated additional funding ($40 million) over four years to reduce costs and improve health services. A proportion of these funds is to be directed to develop quality and outcome indicators for the health care sector18.

4.2.6 Other Commonwealth Programs

Funding was provided in 1996 to develop a model for national use via the Integrated Quality Management Model Project, which involved a range of activities and a number of participating hospitals. The project has been considering the application of indicators around the principles of the "Clinical Value Compass" (Hospitals Corporation of America) according to targeted conditions, which include: Through a cooperative effort by the ACHS and National Centre for Classification of Health (NCCH), twenty nine of the ACHS clinical indicators were applied to determine the ability to access required indicator data from ICD-9-CM coding. Results (yet to be released) have shown that certain indicator criteria can be obtained from ICD-9-CM coding but very few indicators (two) could be exactly determined (numerator and denominator data) from the coding system19. There is a better capacity to determine at risk populations (denominators) than actual events of interest (numerators). As such, the coding system is of some use in data extraction by way of "narrowing the field" of potential cases, but cannot be relied upon for accurate data retrieval.

The National Demonstration Hospital Program has also defined 20 performance indicators, which are restricted to access and efficiency. However, it has been reported that the operational definitions are crude and inadequate for routine application15.

5.0 International Programs

There is a multiplicity of indicator programs of various dimensions operating in other countries, which can also be useful in informing the development and application of indicators in Victoria. A number of initiatives in the United States and United Kingdom are reviewed.

5.1 Joint Commission on Accreditation of Healthcare Organisations (JCAHO)

As an initiative of the JCAHO the Information Management (IM) System has been in development since 1986. As a national comparative performance management system, the IM System measures clinical performance and provides data to improve patient care and meet the information needs of all stakeholders. Forty two performance measures have been developed with known reliability and demonstrated relevance and validity. The measures have been established according to specified criteria, including: The IM System has a single database that stores patient data at the episode of care level. This allows for risk adjustment of rates and provision of quarterly reports with control and comparison charts. The System began accepting data from hospitals in January 1994 (peri-operative and obstetric) and it was originally intended that all accredited hospitals would use the IM System. This requirement was dropped in January 1995 due to pressure from the American Hospitals Association20, 21.

In January 1997 a new indicator initiative was launched by the JCAHO. The ORYX Initiative provides for choice of performance management system and represents a further attempt by JCAHO to incorporate performance measurement into the accreditation process. Hospitals choose from sixty approved vendors of clinical information systems and are required to select a minimum of two clinical measures which address more than 20% of an organisations patient population. Hospitals will begin to submit data for selected indicators (via the nominated vendor) by 199921, 22. The indicators are summarised in Table 3. Other indicators planned for introduction relate to depressive disorders, long term care and home infusion therapy.

Table 3: Summary of IM System Indicators (JCAHO)
Category Indicator
Perioperative Complications within 2 days of procedures involving anaesthesia (4 indicators)
Intrahospital mortality within 2 days of specified procedures
Obstetric Caesarean section
Vaginal birth after caesarean section
Low birth weight
Newborn outcomes
Apgar score for infants 1000-2500 grams
Cardiovascular Post-op. LOS for CABG surgery
Timing of thrombolytic therapy for AMI
Congestive heart failure
Post-op LOS for PTCA
Death following AMI, PTCA, CABG
Oncology Surgical pathology report present
Staging documented
Estrogen Receptor Analysis results
Complete surgical resection of tumour
Complete preoperative colon exam prior to resection
Trauma Vital signs and Coma Scales in ED (2 indicators)
Endotracheal intubation-comatose intracranial injuries
Timing of head CT scan
Timing of specified procedures-neurosurgical, orthopaedic, abdominal (3 indicators)
Death following pneumothorax/haemothorax, BP < 70 first 2 hours (2 indicators)
Medication use Creatinine clearance estimated/measured
Timing of prophylactic antibiotic administration by surgical procedures (17 groups)
Demonstration of self blood glucose monitoring/insulin administration
Measured drug levels-Digoxin, Theophylline, Phenytoin, Lithium (4 indicators)
Numbers of medications at discharge
Infection control Surgical site infection by procedure (17 groups)
Ventilated inpatients who develop pneumonia (13 groups)
Primary blood stream infection (13 groups)
Source: JCAHO IM System Indicators of Quality

5.2 Health Care Financing Administration (HCFA)

In 1986, the HCFA published hospital-specific risk adjusted mortality rates using administrative databases and casemix adjustment models. However, there was protracted criticism and concerns regarding the accuracy of the data and its interpretability. Publication was aborted in 1992 after an internal review failed to demonstrate validity of the indicator as a measure of the quality of care.

Two important principles have been learnt from HCFA. Firstly, that indicators chosen for public release must be valid and able to withstand scrutiny, and secondly, that if information is used for comparative accountability, it is necessary to ensure the active involvement of providers in the development process23.

HCFA have now adopted a new approach-the Health Care Quality Improvement Initiative-a collaborative approach between HCFA, providers, hospitals and societies to develop indicators of quality of care. HCFA facilitates data collection and analysis and provides confidential feedback to promote the use of data for quality improvement and benchmarking. An example is, the HCFA HCQII Cooperative Cardiovascular Project, whereby there are twelve indicators for the management of Acute Myocardial Infarction (AMI). These are largely measures of technical proficiency based upon accepted guidelines for the management of AMI6,15.

5.3 National Committee for Quality Assurance (NCQA)

NCQA undertakes assessment and reports on the quality of managed health care plans in the United States. This provides information which enables consumers and purchasers to distinguish between plans and make informed choices. It achieves this through accreditation of health plans and provision of report cards based upon set standard performance measures developed by NCQA and known as HEDIS (Health Plan Employer Data and Information Set). HEDIS V.3.0 provides a common dataset and NCQA releases information about the plans it has reviewed as requested15,24. The performance indicators relate to the areas of:

Preventive services-immunisation, cholesterol/mammography screening, pap tests

5.4 Maryland Hospital Association

The Maryland Quality Indicator Project (QIP) was established in 1985, initially as a research initiative in search of valid indicators, reliable methods of data collection, clarity of analysis presentation and applicability of quantitative research. The program is aimed at internal users to stimulate quality improvement rather than for external comparison. More than 1000 organisations participate at the multinational level25,26. Performance data are not risk adjusted but monitor trends over time. The indicators are not seen as direct quality measures per se, but trend analysis allows for assessment of the level of quality. Reports are provided quarterly and organisations are prohibited from using the data for external marketing.

There are ten inpatient outcome indicators (implemented 1986) and five ambulatory care indicators (implemented 1991) as listed in Table 4.

Table 4: Maryland QIP Indicators
Category Indicator
Inpatient Hospital acquired infection
Surgical wound infection
Inpatient mortality
Neonatal mortality
Perioperative mortality
Caesarean section
Unscheduled readmission following inpatient care
Unscheduled readmission following ambulatory procedure
Unscheduled returns to a special care unit
Unscheduled returns to the operating room
Ambulatory Unscheduled returns to the emergency department
Patients in the emergency department for > 6 hours
Emergency department x-ray report discrepancies
Patients leaving the emergency department before completion of treatment
Cancellation of ambulatory procedures
Source: Quality & Outcome Indicators for AHS 1996

5.5 Cleveland Health Quality Choice (CHQC)

The CHQC is a collaborative effort established in 1989, to measure and improve quality and affordability of health care services. The program is based upon a 'purchasing for value' model and hospitals submit risk-adjusted data for observed outcomes of care. Provider networks reward hospitals for offering quality care at reasonable cost. The indicators relate to patient satisfaction and treatment outcomes in four selected service areas as shown in Table 56,15.

Table 5: CHQC Indicators
Category Indicator
Patient Satisfaction
Surgical Outcomes (LOS) CABG
Major blood vessel repair/bypass
Lung resection
Bowel resection
Spinal surgery
Fractured hip/replacement
Prostatectomy
Hysterectomy
Medical Outcomes Acute myocardial infarction
Congestive heart failure
Stroke
Pneumonia
Chronic obstructive airway disease
Intensive Care Outcomes Mortality
LOS
Source: Quality & Outcome Indicators AHS 1996.

5.6 National Health Service (NHS) Programs-United Kingdom (UK)

There has been relatively less development in terms of quality and outcome indicators in the UK. League Tables have been published by the NHS with indicator data relating to waiting times, managerial performance and mortality rates. The data are not risk-adjusted nor audited and there is little evidence to suggest that the results have effected provider behaviour or the quality of health care15.

In 1993 the Central Health Outcomes Unit (CHOU) was established to promote the use of health outcomes information, particularly for policy and planning purposes. Minimum datasets were developed for public health and population health. In recognising the gap in clinical information a report was commissioned by the NHS to establish the feasibility of a number of clinical outcome indicators27. Multi-disciplinary working groups were drawn together to identify potential indicators which could be extracted from routine datasets. Following initial screening, the feasibility of the indicators was determined according to pre-defined criteria. This work was undertaken co-jointly by CHOU and CASPE consulting with medical colleagues nominated by the Medical Royal Colleges.

The feasibility studies found that abstraction of indicators from NHS data was possible however, key constraints were highlighted, particularly in relation to completeness and quality of data, lack of events linkage and lack of severity adjustment. In its interim report the working group recommended that further development work should proceed, whilst emphasising the necessity for higher quality, more effective clinical data collection if the NHS is to have better and more appropriate indicators for monitoring clinical performance27.

In July 1997, Britain's Department of Health, in association with the British Medical Association, announced its intention to publish measures of clinical performance. Fifteen indicators have been identified for reporting, based on the work outlined above and these are listed in Table 6. Hospitals are to be provided with data that shows how they are comparing with national averages for each of the indicators and, once the indicators have been assessed for scientific validity, the Department of Health intends to make the information public28.

Table 6: Clinical Indicators of Hospital Performance (NHS)

Deaths in hospital within 30 days of surgery
Emergency readmissions within 28 days of discharge
Wound infection in hospital after surgery
Discharge home within 56 days of emergency admission from home with stroke
Surgery for recurrence of hernia after previous surgery
Deaths in hospital within 30 days of emergency admission for AMI
Damage to organs in hospital after surgery
Pulmonary emboli in hospital after surgery
Cardiac complications in hospital after surgery
Complications in the central nervous system after surgery
Adverse events related to the use of drugs in hospital
Repeat operation after previous surgery on the prostate
Discharge home within 56 days of a fractured neck of femur
Deaths in hospital within 30 days of a fractured neck of femur
Frequency of dilation and curettage in women under 40 years of age.
Source: Wise 1997.

Back to Index Page