Why performance indicators have a place in health policy.

Despite the mixed results of Brown and colleagues' review of the evidence for the use of performance indicators in health policy, this paper argues that they have an important place. Healthcare organizations cannot rely on altruism alone to motivate improved performance. Berwick, supporting the use of performance indicators in healthcare, argues "threats to survival are necessary to build will for improvement." He argues that the job of managers is to create organizations where such threats are clearly perceived, but balanced against a culture of "safety" in which individuals can learn and improve the care provided. This step in the causal chain gets insufficient attention from the "KAB+" evaluation model that Brown and colleagues employ. The use of performance indicators in publicly funded healthcare systems goes beyond arming the "consumer" of healthcare with relevant information; it is a fundamental question of democratic accountability. Methods for evaluating the evidence base of public policy must take into account the contextual (economic, social and political) factors that support or impede the achievement of policy objectives.