Performance measurement: is it now more scientific?

The role of performance measurements and clinical indicators has changed from being a minor component in the management of health care to one where the demands for greater accountability, safety, efficiency, and quality have accentuated the role of measurement and reporting. For those who have been involved in the development of indicators this will be seen as progress. However, the increased demand also requires that the field is associated with greater scientific rigour [1]. In this issue, three papers provide a new approach to one component that is used to define indicators: how to develop a quality framework. The framework is the first of four stages that are required in the application of clinical indicators, namely: (i) defining the measures (derived from the framework); (ii) collecting the data; (iii) appropriate analyses and interpretation; (iv) acting on the results. Below we look at some of the methods used during the last 20 years in this first stage of defining indicators and then consider the methods presented in this issue. The first of the following two quotes illustrates that there has always been concern with the lack of measurement. In the second, Smyth summarizes the situation rather well. We must formulate some method of hospital report showing as nearly as possible what are the results of the treatment obtained at different institutions. This report must be made out and published by each hospital in a uniform manner, so that comparison will be possible. With such a report as a starting point, those interested can begin to ask questions as to management and efficiency. If the financial records of any hospital were audited as casually and as ineffectively as in the quality of its patient care, the Administrator and the Governing Board would probably land in gaol. Or barring such an unfortunate happening, the least they could hope for would be financial chaos, unpaid bills, and a richly deserved reputation for business incompetence. Actually there is much more reason to do a continuing and adequate medical audit in a hospital than there is to keep meticulous and informative financial records. The medical audit deals with the life and health of people: the financial audit is concerned only with money. By the early 1980s, the measurement of quality began to be focused on the taxonomy given by Donabedian [2] who classified measures as being related to structure, process, or outcome. In the 1990s the …