Baker's Decalogue for high-performance healthcare organizations

Jordi Varela
Editor

 

Americans trust that competitiveness is the essence of human activity, which has made them the world's leading power, with China's permission. This principle, however, has not worked for them when they have applied it, without palliative, to their health care system, which is showing clear signs of poor performance: it’s very costly, it’s inequitable and it’s showing poor results. For this reason, some public health care organizations such as Veterans Affairs and Medicare, or private, such as Mayo Clinic, Cleveland Clinic or Kaiser Permanente, are trying to put sanity, analyzing what are the keys to improve the performance of the system.

Measuring efficiency: is it going well?

Mª Luisa de La Puente

While the concept of efficiency is easy to understand if we consider it as the system that uses resources (inputs) to improve the health of the population, it's not as easy to measure as it appears due to the multiple methodological problems. The relationship between inputs and outcomes in the health sector is influenced by multiple factors external to the control of the health sector itself.

The European Union Health System Performance Assessment (HSPA) expert group has recently published a report on this (1).

It defines efficiency as the quotient between the inputs of the system (equipment, resources) and its outputs (the number of patients treated, for example) or its outcomes (the number of years of life gained, for example). He accepts them both but warns that using outputs as an approximation of outcomes can lead to false interpretations. It also highlights the importance of differentiating efficiency from cost control, since cost control is only concerned with reducing inputs without measuring the outputs/outcomes that that reduction causes.

In a health system, efficiency can arise for two different but related reasons. Efficiency materializes:

 1) When the same result could be produced, or even better, consuming fewer inputs, and

 2) When resources are spent on a mix of services that maximize the health of society as a whole (outcomes). These two typologies of efficiencies are conventionally cited, respectively, as technical efficiency and allocation efficiency. The allocation efficiency can be produced on a macro basis (paying attention to the service with the best cost/effectiveness ratio) and on a micro character (giving the treatment with the best cost/effectiveness ratio). The OECD idea of waste is associated with the notion of technical efficiency (2).

A survey is carried out in the 29 countries that are part of the group of experts, of which 22 answered. The survey only explores technical efficiency, since the assignment would require information on the relative value of the outputs of the services that don't it's available in most of the investigated countries. Half of the respondents state that they don't have a unified system to measure efficiency. Of the other half, approximately 40% respond that they consider the relationship between intermediate inputs and outputs, 40% between inputs and outcomes, and the remaining 20% consider the two previous possibilities. 80% responded that the hospital area is subject to regular measurements, not so much for strategy as for lack of information from other health areas such as primary care, mental health or social and health care. Technical efficiency in hospitals is also measured as it's the functional area with the highest cost. The results show how, although European countries place improving efficiency as their priority, the vast majority have real problems when it comes to having the necessary methodology and instruments to measure it.

The report presents as an example of evaluation of technical efficiency the management of the demand of acute pathology, which requires evaluating three moments of the process: before hospitalization, during the stay and after discharge, expanding the spectrum of the analysis to other areas such as primary care and social health care.

The OECD report insists on the same recommendation to broaden the spectrum when looking at the overuse of hospitals. This is exemplified by the excessive use of emergency services in mild pathologies and the excessive use of emergency and hospital services in chronic pathologies, both of which can be better managed in other devices. It also illustrates this with different examples of how certain OECD countries have made these changes.

The recommendations that emerged after reading the OECD report are:

1. It’s essential to have more homogeneous instruments for measuring and evaluating the efficiency of health systems that serve to guide decision-making.

2. It’s dangerous to make decisions based on comparisons and benchmarks with outputs/outcomes that are not well validated or contextualized.

3. When analyzing efficiency, as opposed to the concept of cost control, it's essential to broaden the spectrum of analysis to all services that address the care process. This formula also allows crossing the border between technical and assigned efficiency.

It seems, therefore, that the measure of efficiency is still at a very early stage. Improving the information that supports efficiency measurement is essential to support change. On the one hand, it will avoid inappropriate policies, on the other, it favours the evaluation of services with greater precision. Also, finally, it will promote the awareness of the population about what it means to obtain appropriate care, a necessary aspect in our country.

Bibliography

1. EU. Report by the Expert Group on Health System Performance Assessment. TOOLS AND METHODOLOGIES TO ASSESS THE EFFICIENCY OF HEALTH CARE SERVICES IN EUROPE. 2019

2. OCDE. Tackling wasteful spending on health. 2017.

Measuring the effectiveness and value of clinical practice

In the "XIV Conference of the Sign Foundation", Jens Deerberg-Wittram, Director of the Boston Consulting Group, gave the inaugural lecture entitled "From volume to value". It was a very timely speech, at a time when the obsessive control of budgets and waiting lists prevents clinicians and managers from reflecting on what contributes so much care activity to society. The concept of value expressed by the German speaker is very new for healthcare managers, who tend to understand clinical effectiveness as a rhetorical concept more typical of epidemiological studies.

Value-based healthcare: the patient's perspective

Glòria Galvez

More and more organizations are adopting the new model of value-based healthcare (VBHC) where, according to the formula developed by Michael Porter:

                                                         Results that matter to the patient

                                        Value = ______________________________

                                                                           Costs

In order for the results to be measured correctly and standardized, the International Consortium for Health Outcomes Measurement (ICHOM) -a non-profit organization recently joined by Vall d'Hebron Hospital- is defining sets of indicators standardized by clinical conditions. In this line, the Vall d'Hebron Hospital, which is implementing this new model of care, has set up working groups to define the indicators that they provide value to patients for the clinical conditions of stroke and localized prostate cancer.

Measuring results in health is still very complicated

In order to evaluate health institutions based on the value they provide, health outcomes must be measured. However the efforts to achieve this are bearing dismal results. Pay-for-performance initiatives are drifting in an ocean of indicators that don’t translate into anything too operational. To give some examples, in the US, CMS (Medicare and Medicaid) handles nearly a thousand indicators to promote new funding models (see Health Affairs Blog "The Quality Tower of Babel") and, not so far away, in the Results Central of Catalonia (AQuAS), more than 300 indicators are recorded. Everything suggests that the excess of information will not bring light if we are not able to clarify what it means to add value to people's health, and to make this statement comprehensible, we must distinguish between two different approaches:

Health value for citizens

A long life free of disability is a goal that most mortals share but this indicator is not very useful for service providers because the impact of the health system on life expectancy barely reaches 20%.

Nurses: (+) training (-) workloads = (-) mortality

A few months ago, Mireia Subirana, Director of Care at "Consorci Hospitalari de Vic" explained in a post the results of her doctoral thesis that can be summarized as: "more nurses and more training (in hospital wards) was associated with better clinical outcomes". Following this thread, The Lancet has just published the results of a retrospective observational study that has explored whether the nurses training levels and workload ratios could influence the mortality of patients admitted for medium complexity scheduled surgery.

It’s an important work undertaken in 300 hospitals in 9 European countries by surveying 26.516 nurses and analysing 422.730 hospitalization surgical episodes. Despite the expected methodological difficulties of a project of this nature, it can be considered as a rigorous study.