Health Performance Measurement in the Public Sector Principles and Policies for Implementing an Information Network (1999) / Chapter Skim
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2 Putting Performance Measurement in Context
2 Putting Performance Measurement in Context
Pages 30-58
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It is within this context that performance goals are defined and then translated into performance measures, for which information systems must be able to produce data of the needed scope and quality. This chapter reviews the characteristics and uses of performance-based management and accountability systems, some of their strengths and limitations, and examples of their application in federal and state government settings and in the private sector for health care organizations.
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For example, state substance abuse or mental health agencies often contract with private providers to deliver publicly funded services. With performance-based contracts, those providers can be held responsible for certain overall outcomes among the people they serve.
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Problems encountered in earlier efforts to apply performance-based systems offer lessons for current performance-based approaches (Florida Office of Program Policy Analysis and Government Accountability, 1997; U.S. General Accounting Office, 1997c)
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As noted earlier, one would expect the goals and objectives to focus on outcomes, not process. Such is certainly the case for the two recent federal initiatives in this area the National Performance Review and the Government Performance and Results Act (GPRA)
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or that guard against possible but rare adverse events (e.g., water treatment) , it may be more meaningful to focus on measures that track risk reduction activities and capacity to respond than on outcome measures that would generally show little change in the short term and few differences from program to program.
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Including too many measures at this level can divert attention from key outcomes without improving the usefulness of the performance information as a management tool. These measures must, however, be chosen carefully, espe
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The next step for a performance-based system is to apply the information obtained from performance measurement to assess progress toward desired outcomes. If progress is not adequate, performance information can inform steps taken to improve the likelihood of achieving outcome goals in the future.
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The state might also want to assess progress toward this goal by local immunization programs across the state. Consumer-oriented reporting of performance information is illustrated by "report cards" on health care provider performance, such as that developed in conjunction with the Mental Health Statistics Improvement Program (MHSIP)
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The aim is to motivate program staff or communities to achieve desired outcomes (e.g., immunization rates, access to services, desired community behaviors) by comparing performance measurement information with targets set for program goals.
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States that repeatedly fail to meet the required level of performance face the loss of up to 40 percent of their Substance Abuse Block Grant funds (Substance Abuse and Mental Health Services Administration,1998~. Complicating the federal-state relationship on this issue are regulations issued by the Food and Drug Administration (1996)
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Third, the performance requirement and its associated penalty are not related to the typical program goals and strategies of state substance abuse agencies. Few of these agencies have any enforcement authority regarding tobacco sales, and states are specifically prohibited from using their Substance Abuse Block Grant funds for any enforcement activities other than inspections of sales outlets.
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Annual performance plans were submitted beginning in 1998 for fiscal year 1999, and the first performance reports are to be issued in March 2000. Each of the agency reporting requirements contributes to the overall performance-based management system envisioned under GPRA.
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For some agencies, a lack of baseline data has made it difficult to establish annual performance goals. Use of Performance Measures in the Maternal and Child Health Services Block Grant Program Within DHHS, MCHB has responded to the new GPRA requirements in part by introducing a performance measurement component into the Maternal and Child Health Services Title V Block Grant to States Program (see Maternal and Child Health Bureau, 1997, 1998a)
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The Bureau has worked in partnership with the states, through the Association of Maternal and Child Health Programs and other channels, to reach agreement on the outcome measures and 18 national performance measures to be used. The outcome measures represent long-term health improvement goals to which Title V programs should be contributing but generally do not control.
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The new program aims to provide time-limited assistance to needy families and to reduce their dependence on government benefits by promoting job preparation, work, and familial responsibility through marriage. States have greater flexibility than under previous programs to specify who receives benefits, under what terms, and for how long, but they must submit reports demonstrating that their performance is in compliance with the provisions of the legislation and achieving desired outcomes.
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Such efforts are generally driven by management-oriented state legislatures whose members believe that the implementation of improved management controls within state government systems will lead to more effective government overall. A 1996 study found that 45 states are using performance measures in various ways (Florida Office of Program Policy Analysis and Government Accountability, 1997~.
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to specific program activities or funding needs. A recent review of the state's strategic plan (Oregon Progress Board, 1997)
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. Today's state-level performance monitoring and budgeting efforts vary in their focus, with their approach depending on which of three overall purposes they serve (Florida Office of Program Policy Analysis and Government Accountability, 1997~: 1.
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More recently, quality improvement and performance measurement programs have altered this accountability framework by introducing continuous monitoring of the processes and outcomes of care for populations of patients. As under the performance-based budgeting approaches described above, clinical performance information provides management tools that can be used to promote improvements in health care.
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National Committee for Quality Assurance One of the most prominent performance measurement tools in health care is NCQA's Health Plan Employer Data and Information Set (HEDIS) , a set of standardized measures for comparing the quality of care provided by participating health maintenance organizations (National Committee for Quality Assurance, 1997a)
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The measures adopted by FACCT are field tested by health plans and group practices as part of the development process. FACCT has placed special emphasis on the consumer perspective and seeks to measure elements of health care quality that are important to consumers.
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Joint Commission on Accreditation of Healthcare Organizations JCAHO has long served as one of the principal accrediting bodies for health care facilities. Its accreditation programs now include hospitals, home care agencies, long-term care facilities, behavioral health services, ambulatory health care providers, laboratories, and health care networks.
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Recognizing that selection of a measurement system and use of specific performance measures will be unfamiliar tasks for some of the participating organizations, JCAHO has developed a guidebook and other resources to help organizations evaluate and select a measurement system that will meet their needs. Lessons for Publicly Funded Health Programs The evolution of performance measurement in health care in the private sector offers lessons to those developing performance measures for publicly funded health programs.
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After reviewing performance measurement experience in other contexts, the panel concluded that several principles should guide current efforts to implement performance measurement for publicly funded health programs. Link performance measurement to program goals.
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This principle is consistent with the GAO (1996) recommendation regarding GPRA that "hierarchies" of performance goals and measures are needed to reflect differing roles and responsibilities at various organizational levels.
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Pediatrics 90:774. American Managed Behavioral Healthcare Association 1995 Performance Measures for Managed Behavioral Healthcare Programs (PERMS)
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Washington, D.C.: National Academy Press. Joint Commission on Accreditation of Healthcare Organizations 1998a Accreditation Information.
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Substance Abuse and Mental Health Services Administration 1998 SAMHSA's Tobacco Activities: Implementing the Synar Requirements Under the Substance Abuse Prevention and Treatment Block Grant.
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Wholey, J.S., and H.P. Hatry 1992 The case for performance monitoring.
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