A Performance Measurement Framework for Canadian Hospitals, 2013

pic pic A Performance Measurement Framework for Canadian Hospitals, 2013 Standards and Data Submission

Our Vision Better data. Better decisions. Healthier Canadians. Our Mandate To lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that improve health and health care. Our Values Respect, Integrity, Collaboration, Excellence, Innovation

Table of Contents Executive Summary... iii Introduction... 1 Background... 2 A Renewed Health System Performance Measurement Framework for Canada... 2 The Performance Assessment Tool for Quality Improvement in Hospitals... 4 Cascading Systems and a Hospital Performance Framework for Canada... 5 Hospital Performance Framework... 11 Conclusions... 17 Appendix A: Information Requirements for Stakeholders in Health Care Systems... 19 Appendix B: Key Concepts and Definitions From CIHI s New Health System Performance Measurement Framework... 21 Appendix C: Key Concepts and Definitions From the PATH Framework... 25 References... 27

Executive Summary Performance measurement and assessment are central to securing accountability for the health system s actions and outcomes to citizens, patients and payers. However, given the variable information needs that the many different stakeholders involved in health systems have, it is likely that the information they require varies across many levels of detail, time frames and levels of aggregation. This document outlines a hospital performance measurement framework that aligns with the Health System Performance Measurement Framework recently proposed by the Canadian Institute for Health Information (CIHI). Over the past several years, much energy has been put into creating numerous international and national frameworks with the purpose of assessing health systems and health organizations performance. Rather than produce an entirely new framework to assess hospital performance, this document proposes a hospital performance framework that cascades from CIHI s national Health System Performance Measurement Framework. This allows priorities at the system level to be aligned with priorities at the hospital level. To inform the development of the Hospital Performance Framework, this document also draws upon the internationally assessed Performance Assessment Tool for Quality Improvement in Hospitals (PATH) framework developed by the World Health Organization (WHO) Regional Office for Europe. Development of the PATH framework was informed by international experts and a thorough review of academic literature across countries and thus serves as a good starting point for extending the Health System Performance Measurement Framework to hospital performance. To develop a hospital performance framework that cascades from the health system framework, it is necessary to reconcile the different performance boundaries that apply when considering a health care organization as opposed to a health system. A hospital performance framework will put more emphasis on particular areas of the health system framework and less emphasis on other areas included in the wide scope of the health system that are not relevant to hospital assessment, such as public health or health promotion. CIHI s Health System Performance Measurement Framework represents the health system in four distinct quadrants and how they interact: Social determinants of health; Health system inputs and characteristics; Health system outputs; and Health system outcomes. To produce a cascading hospital performance framework that links to the health system framework, it is necessary to consider how these quadrants are related to hospital performance. iii

The first quadrant, social determinants of health, represents the factors outside the health system that influence the health of a population. These factors include genetic endowment, social position, life conditions and the physical environment, and they are external to the processes of both the health system and hospitals. However, these factors need to be considered in performance assessment exercises, as they will influence what inputs are necessary to attain the valued outcomes of both the health system and the hospitals within it. The second quadrant represents the inputs of production. At the health system level, inputs refer to the resources available to be used and to the distribution and allocation of these resources, including characteristics of the health system such as governance and leadership capacities. At the hospital level, inputs reflect a subset of the health system s inputs, in particular those that are related to the resource allocation decisions that will be made regarding the distribution of resources within hospitals. This includes hospital characteristics such as management, innovation and cross-sectoral learning. The third and fourth quadrants reflect health system and hospital outputs and outcomes, respectively. Similarly to inputs, hospital outputs and outcomes will reflect only a subset of the health system s outputs and outcomes. The main objectives of hospitals will be linked to the three ultimate aims of the health system. These aims are outlined by CIHI s Health System Performance Measurement Framework as Improving the level and distribution of health in the population; Improving the health system s responsiveness to the needs and demands of Canadians; and Improving value for money to ensure health system sustainability. Hospitals are able to contribute to the attainment of each of these goals; however, their performance alone is not sufficient to influence any one of these outcomes. When considered at the systems level, the outcomes produced by hospitals reflect part of the desired outputs, or intermediate objectives of the health system. Thus the desired outcomes or main objectives of hospitals correspond to the capacity of the health system to provide access to timely, continuous and effective health services. To produce a final hospital performance assessment framework, the four cascaded hospital quadrants are used as a basis to represent the hospital production process within the broader health system and the wider demographic, economic and political context. This mapping allows clear linkages between the hospital performance and health system frameworks so that it is possible to clearly identify how these two levels of analysis are connected. The hospital inputs and outputs outlined in CIHI s Hospital Performance Framework draw heavily from the PATH framework. On the input side, the framework identifies five key hospital inputs that interact to attain hospital outputs and outcomes: Responsive governance; Hospital resources and staff orientation; Efficient allocation of staff resources; Appropriate processes of care; and Hospital innovation and learning capacity. iv

Responsive governance refers to the degree to which a hospital is responsive to community needs, ensures care continuity and coordination, promotes health, is innovative and provides care to all citizens. Hospital resources refers to the amount of physical and human resources used to deliver patient care in a hospital. Staff orientation refers to the degree to which hospital staff are appropriately qualified to deliver the required patient care, have the opportunity for continued learning and training, work in positively enabling conditions and are satisfied with their work. Efficient allocation of resources measures how resources are combined to produce health services to meet the population-based demands and needs of a society. Ensuring appropriate processes of care refers to the hospital s capacity to continually adapt to meet the health needs of the population it serves through innovation and learning and also by adjusting the allocation of resources across hospital services. Hospital innovation represents the implementation of an internally generated or borrowed idea whether pertaining to a product, device, system, process, policy, program or service that was new to the organization at the time of adoption. Learning capacity in the health system refers to the extent to which the system is skilled at creating, acquiring, and transferring knowledge, and at modifying its behaviour to reflect knowledge and insights. 1 Given the broad context of the health system, hospitals use responsive governance and the resources available to them to make resource allocation decisions and to adapt to the latest innovations. These actions allow them to ensure that the appropriate processes of care (both non-clinical and clinical processes) are being carried out within the hospital and enforced. Ensuring these inputs are in place should allow the five outputs identified to be attained: Access to services; Clinical effectiveness; Safety; Patient-centredness; and Coordination of care. All of these outputs refer to the degree to which successful transactions are achieved between patients and providers in the course of actual care delivery, taking into consideration patient and community needs. Attaining these outputs signifies a good likelihood that hospital outcomes, and in turn health system outputs and outcomes, will be achieved. Access to comprehensive hospital services corresponds to the range of hospital services available and the hospital s ability to meet the needs of the population or a particular patient without financial, organizational or geographical obstacles standing in the way of seeking or obtaining these services. v

Clinical effectiveness refers to the process by which a hospital, in line with the current state of knowledge, appropriately and competently delivers clinical care or services to, and achieves desired outcomes for, all patients likely to benefit most. Safety is achieved when a hospital has the appropriate structure and uses care delivery processes that measurably prevent or reduce harm or risk to a patient s health care providers and the environment. Patient-centredness occurs when a hospital places patients at the centre of care and service delivery by paying particular attention to patients and their families needs, expectations, autonomy, access to hospital support networks, communication, confidentiality, dignity, choice of provider and desire for prompt, timely care. Coordination of care refers to the degree to which a hospital ensures that patients and clinicians have access to, and take into consideration, all required information on a patient s conditions and treatments to ensure that the patient receives appropriate health care services. It also refers to the degree to which the hospital ensures that the continued needs of a patient are met upon discharge, including referral to community resources or partnership with other health care professionals. These hospital outputs are necessary to achieve the three hospital outcomes: Patient survival and degree of health recovery and health protection; Positive patient experience with hospital services; and Hospital efficiency. These three hospital outcomes represent subsets of the health system outputs necessary to achieve the three health system goals: health improvement, responsiveness and value for money. As a hospital makes up only one entity in the health system, its outcomes cannot make up the entire health system outcome but merely contribute to its attainment. The full attainment of the health system s goals will depend on the contribution of all parts of the health system as well as their interaction. The first hospital outcome identified relates to health improvement and is threefold, encompassing patient survival, the degree of health recovery attained and health protection. This tripartite structure takes into consideration the fact that different outcomes may be more meaningful for different patients. Patient survival is of overriding importance to most patients within a hospital and can be measured over various periods appropriate to the medical condition. Degree of health or recovery achieved or retained at the peak or steady state may be more meaningful for older patients who weigh other outcomes more heavily. Health protection refers to ensuring that a patient s health will be protected upon discharge through continuing integrated care and patient behaviours. This aspect is important, as it refers to the sustainability of the previous two outcomes and the degree to which this can be achieved with good integration of the system across different areas. vi

The second hospital outcome identified by the framework is positive patient experience with hospital services. Patient experience with hospital services is related to the provision of hospital care that is respectful of and responsive to individual patients preferences, needs and values, and the assurance that patient values guide all clinical decisions. This hospital goal contributes to the health system goal of improving health system responsiveness. Finally, the third hospital outcome being measured relates to efficiency of hospital care. This outcome assesses the degree to which the previous two goals have been met given the resources used. Any deviation from the maximum health improvement or positive patient experience that could have been produced indicates inefficiency. Attaining this goal contributes to the wider health system objective of value for money. vii

Introduction The Canadian Institute for Health Information (CIHI) recently proposed its new Health System Performance Measurement Framework to help coordinate and align its reporting of performance measurement information across Canadian jurisdictions (provinces, territories and regional health authorities) in a way that supports their performance improvement priorities and helps address the needs of multiple audiences. With coordinated performance measurement efforts, performance comparisons can be made among the provinces, for each province over time or between the entire health system and other national health systems. Properly conducted country performance comparisons may constitute a rich source of evidence and exert a powerful influence on policy. If undertaken carefully, health system performance comparisons can be a powerful resource for identifying weaknesses and suggesting relevant reforms. Measurement is central to securing accountability for the health system s actions and outcomes to citizens, patients and payers (see Appendix A). However, given the variable information needs of the many different stakeholders involved in health systems, it is likely that the information they require varies across many levels of detail, time frames and levels of aggregation. For example, it is likely that a patient requires information on the performance of his or her provincial health system to ensure that the system is able to provide high-quality treatment options that are affordable, and also on the performance of particular providers within the provincial system to decide which provider to seek care from. Similarly, a regulator will be concerned with the aggregate performance of the system as a whole and also with variation across providers within the system. Given the interest of most providers in different levels of performance, this paper outlines a hospital performance measurement framework that aligns with CIHI s Health System Performance Measurement Framework. Over the past several years, much energy has been put into creating numerous international and national frameworks with the purpose of assessing health systems and health organizations performance. Careful examination of national and international frameworks suggests that over time there has been a degree of convergence, both in how frameworks define entities such as the health system and organizations that provide care and in the goals they identify and the levers they identify as being able to influence change. 2 The Performance Assessment Tool for Quality Improvement in Hospitals (PATH) is a framework developed by the World Health Organization (WHO) Regional Office for Europe as a tool that can be used to assess hospital performance. The development of the PATH framework was informed by international experts and a thorough review of academic literature across countries. In particular, the framework was developed through a series of four workshops of experts in the area of hospital performance assessment, a review of the literature on hospital performance and a survey carried out in 20 European countries. Finally, PATH benefited from external scrutiny, as it was piloted in eight countries 3 and implemented in another eight countries in Europe. 4 1

Given the robustness of the PATH framework, it was suggested that it would serve as a good starting point to extend the Health System Performance Measurement Framework to hospital performance, as the underlying principles are similar. This paper proposes the new cascading Hospital Performance Framework for Canada based upon the PATH framework and CIHI s Health System Performance Measurement Framework. The first section of this paper provides a quick introduction to CIHI s new Health System Performance Measurement Framework and the PATH framework. The second section will consider the issues that need to be taken into account when integrating these two frameworks before presenting a cascaded version of the new Hospital Performance Framework. Background A Renewed Health System Performance Measurement Framework for Canada In 1999, CIHI and Statistics Canada launched a project on health indicators: the Canadian Health Information Roadmap Initiative Indicators Framework. 5 This was constructed with two questions in mind: How healthy are Canadians? and How is Canada s health care system performing? The intent of the framework was to provide provinces, territories and health regions with indicators of the overall health of the population served in such a way that they can compare themselves with other regions and over time. 6 This framework was well accepted nationally and recognized internationally. However, in 2012, CIHI recognized a need to update the framework to achieve two things: Better reflect developments in health system performance measurement and health policy, such as the more recent emphasis placed by governments on value for money, patient safety and patient-centredness. Illustrate how the relationships among the various dimensions of performance support the achievement of ultimate health system goals, providing jurisdictions across Canada with a dynamic and actionable framework to enable assessment and discussion of relative performance (Figure 1). 2

Figure 1: CIHI s New Health System Performance Measurement Framework Source Canadian Institute for Health Information, 2013. As the framework represents the health system, the ultimate goal is attaining high performance on health system outcomes, which are defined as improvements in health, health system responsiveness and value for money. To produce its desired outcomes, the health system uses the inputs at its disposal, taking into account the needs and characteristics of the population it cares for. The outputs produced by the health system are considered intermediate objectives that are necessary to achieve the desired system outcomes and that correspond to the capacity of the health system to provide access to timely, continuous and effective health services. Social determinants of health will play an important role in influencing outcomes, particularly health, so they must also be accounted for and, where possible, actions should be taken to ensure they are also addressed. Key concepts and definitions in the Health System Performance Measurement Framework are listed in Appendix B. 3

The Performance Assessment Tool for Quality Improvement in Hospitals The PATH theoretical model for hospital performance was developed with the aim of supporting hospitals in assessing their own performance. In particular, it is a tool to be used by hospital managers for evaluating and improving their hospital services. 4 The conceptual model that serves as the basis for the PATH framework is made up of six interrelated dimensions and is presented in Figure 2. The six dimensions considered are clinical effectiveness, safety, patient-centredness, responsive governance, staff orientation and efficiency. These dimensions were selected as a synthesis of different organizational performance theories. 8, 9 Figure 2: The PATH Theoretical Model for Hospital Performance Source Adapted from Veillard J, Champagne F, Klazinga N, et al. A performance assessment framework for hospitals: the WHO Regional Office for Europe PATH project. International Journal for Quality in Health Care. 2005;17(6):487-496. The dimensions of the PATH framework represent areas of hospital performance that are important both in themselves and in how they interact with each other. Two of the dimensions (safety and patient-centredness) cut across the other four dimensions of hospital performance (clinical effectiveness, staff orientation, efficiency and responsive governance), indicating that the performance of these two dimensions reflects aspects of performance across the other four dimensions. Finally, each dimension is made up of different subdimensions. These subdimensions represent a synthesis of different organizational performance theories and were informed by the review of other conceptual models of performance and expert opinion. 3 The six dimensions are described briefly below. The definitions and related subdimensions are described in more detail in Appendix C. 4

Table 1: PATH Hospital Performance Dimensions Performance Dimension Clinical Effectiveness Efficiency Staff Orientation Responsive Governance Safety Patient-Centredness Short Definition Appropriate and competent delivery of clinical care and services, in line with the current state of knowledge, to achieve desired outcomes for all patients most likely to benefit Optimal use of inputs to yield maximal outputs or care services Appropriately qualified to deliver care, with opportunities for continued learning and training, positively enabling conditions and satisfaction with their work Responsive to community needs, ensuring continuity and coordination of care and the provision of care to all Structure and care delivery processes that prevent or reduce harm or risk to patients, care providers and the environment Patients placed at the centre of care delivery, paying attention to the needs of patients and their families Source Veillard J, Champagne F, Klazinga N, et al. A performance assessment framework for hospitals: the WHO Regional Office for Europe PATH project. International Journal for Quality in Health Care. 2005;17(6):487-496. Cascading Systems and a Hospital Performance Framework for Canada As outlined above, the aim of CIHI s Health System Performance Measurement Framework is to provide policy-makers and managers with a tool geared toward the improvement of health system performance. This framework attempts to capture all factors that encompass the health system, as well as the factors that will influence the attainment of key health system goals. The Health System Performance Measurement Framework adopted the WHO s definition of a health system A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. 10 indicating its inclusive approach of public health activities, health promotion and intersectoral action. The first consideration that arises when using this tool to develop a related hospital performance framework is how to reconcile the different performance boundaries that apply when considering a health care organization as opposed to a health system. It is clear that the emphasis needs to be on particular areas of the framework, as many of the areas included in the wide scope of the health system are not relevant to hospital assessment. For example, Figure 3 illustrates the potential production process of a health system, with examples of costs and physical inputs put into the system and a selection of outputs and valued outcomes that are produced. This same production process is represented in the Health System Performance Measurement Framework, where inputs and characteristics are translated into outputs and then outcomes. The different shades in Figure 3 represent different boundaries of the health system; it starts by considering only medical care and extends to consider all factors that influence health. Across these boundaries, many of the valued outcomes of the system do not change for example, health improvement and risk protection are valued outcomes for medical care, public health and health promotion, intersectoral action, as well as economic growth and public-sector investment. However, the physical inputs that contribute to the attainment of these valued outcomes will differ depending on the choice of boundaries. 11 5

In an evaluation of health system performance, it is important to both consider the physical inputs that correspond to the health system as defined and ensure that the valued outcomes being assessed also represent only the contribution of those particular inputs. For example, when assessing the performance of a hospital, it is crucial to isolate the contribution of medical care to health improvement and to adjust for any contribution of other activities, such as public health and health promotion, and of contextual factors, such as the economic, political and demographic contexts. For a cascading hospital performance framework to be created and mapped onto the Health System Performance Measurement Framework, it is thus necessary to consider which are the valued outcomes, or goals, of the hospital production process and how those valued outputs contribute to the broader production process of the health system itself. Figure 3: Health System Production Process at Different Health System Boundaries Source Adapted from Papanicolas I, Smith PC, Culyer T, Tsuchiya A. The theory of systems level efficiency in health care. Encyclopedia of Health Economics. Elsevier. In press. There are three ultimate aims of the health system, as outlined by the Health System Performance Measurement Framework (Figure 1): Improve the level and distribution of health in the population; Improve the health system s responsiveness to the needs and demands of Canadians; and Improve value for money to ensure health system sustainability. Hospitals are able to contribute to the attainment of each of these goals; however, their performance alone is not sufficient to influence any one of these outcomes. Indeed, when considered at the systems level, the outcomes produced by hospitals reflect part of the desired outputs, or intermediate objectives of the health system, and correspond to the capacity of the 6

health system to provide access to timely, continuous and effective health services. Table 2 relates the four quadrants of the health system to the valued outputs and inputs of a hospital to facilitate the specification of objectives for these different levels of analysis. Table 2: Relating Hospital Performance to Health System Performance Health System Social Determinants of Health Relationship Between Health System and Hospital Care Structural factors influencing health Biological factors Psychosocial and behavioural factors Material factors Social determinants of health present in the health system will influence the types of services a hospital must provide and the types of outcomes it is able to achieve. Health System Inputs and Characteristics Leadership and governance Health system resources Efficient allocation of resources Adjustment to population health needs Health system innovation and learning capacity Health system inputs determine how many and what inputs are available for hospitals. Hospital inputs are a subset of health system inputs. Health System Outputs Access Promotion and prevention Efficiency and effectiveness Health system outputs will influence patient need and the severity of hospital patients.* Hospital outputs are a subset of health system outputs. Health System Outcomes Improve health status Improve responsiveness Improve value for money Hospital outcomes will contribute to health system outcomes to the extent to which they are able to improve health status and responsiveness and contribute to health system value for money. Hospital Care Social Determinants of Health All of the above applied to the population the hospital is providing its services to Hospital outcomes represent a subset of health system outputs. Hospital Inputs and Characteristics Hospital Outputs Hospital Outcomes Responsive governance Hospital innovation and learning capacity Hospital staff orientation Ensuring appropriate processes are enforced Efficient allocation of resources Physical inputs Access Client orientation Respect for patients Conformity to processes of care Appropriate discharge location Minimum level of adverse events Producing appropriate bundle of services given a patient s needs Improve the health protection and survival offered by hospitals Improve patient experience with hospital services Produce maximum outputs for given inputs in each hospital setting Notes * Health system outputs will influence patient need and the severity of hospital patients; for example, more money invested in health promotion and prevention may lead to fewer and/or less-severe hospital cases. Contributing to health system value for money refers to the allocative efficiency of the system rather than the technical efficiency of the hospital. A hospital may be technically efficient (producing maximum output for input) in a system that is neither technically nor allocatively efficient (producing less than maximum output for inputs spent, as well as the wrong outputs). Source Canadian Institute for Health Information, 2013. 7

The top row maps the key definitions outlined in CIHI s Health System Performance Measurement Framework to each of the four quadrants they belong to. 7 The bottom row uses the same four quadrants, cascaded onto the hospital as the primary unit of assessment rather than the health system. The middle row considers the relationship between each of the existing four health system quadrants and each of the cascaded hospital quadrants. The colours in the table correspond to the colours allocated to each of the four quadrants in CIHI s Health System Performance Measurement Framework and indicate to which of these four quadrants the new cascading hospital quadrants apply. The first quadrant represented in Table 2 relates to the social determinants of health. The social determinants of health represent the factors outside the health system that influence the health of a population. These factors include genetic endowment, social position, life conditions and the physical environment (as defined in Appendix B) and are external to the production processes of both the health system and the hospital. However, these factors need to be considered when assessing the production processes, as they will influence what inputs are necessary to attain the valued outcomes of both the health system and the hospitals within it. The second quadrant represented in Table 2 relates to the inputs of production. At the health systems level the inputs refer to the resources available to be used as well as to the distribution and allocation of these resources. This quadrant also considers the relatively stable characteristics of the health system, such as its governance and leadership capacities and how it adjusts and adapts to reflect the population s health needs, influenced by the social determinants, as well as innovation and learning and the use of information and evidence. At the hospital level these inputs reflect only a subset of the health system inputs, particularly the resource allocation decisions that will be made regarding the distribution of resources within hospitals and across their health care processes to maximize hospital outcomes. This quadrant also reflects hospital characteristics such as management and the ability of the hospital to adjust and adapt in order to reflect the health needs of its patient population, which are influenced by the social determinants and also its capacity to adopt innovation and cross-sectoral learning. The third and fourth quadrants reflect health system and hospital outputs and outcomes, respectively. Similarly to the case for the inputs, hospital outputs and outcomes will reflect only a subset of the health system s outputs and outcomes. However, the main distinction made in these quadrants across the two levels of analysis is that both the outputs and valued outcomes of hospitals are reflected only in the attainment of health system outputs. Indeed, each of the hospital outcomes listed in Table 3 corresponds to the key elements outlined as the key health system outputs and reflects the contribution hospitals make toward attaining the health system outcomes. 8

The distinct areas where hospitals are able to contribute to the input and output quadrants of the health system framework, as outlined by the key areas listed underneath each of the cascaded hospital quadrants, are the same key performance dimensions clearly outlined by the PATH framework: clinical effectiveness, efficiency, safety, patient-centredness, responsive governance and staff orientation. Table 3 indicates how each of these dimensions corresponds to each of the key areas listed in Table 2. Table 3: PATH Dimensions Mapped Onto CIHI s Cascaded Framework PATH Dimension Clinical Effectiveness Efficiency Staff Orientation Responsive Governance Safety Patient-Centredness PATH Definition When a hospital, in line with the current state of knowledge, appropriately and competently delivers clinical care or services to, and achieves desired outcomes for, all patients likely to benefit most A hospital s optimal use of inputs to yield maximal outputs, given its available resources The degree to which hospital staff are appropriately qualified to deliver required patient care, have the opportunity for continued learning and training, work in positively enabling conditions and are satisfied with their work The degree to which a hospital is responsive to community needs, ensures care continuity and coordination, promotes health, is innovative and provides care to all citizens When a hospital has the appropriate structure and uses care delivery processes that measurably prevent or reduce harm or risk to the patient s health care providers and the environment When a hospital places patients at the centre of care and service delivery by paying particular attention to patients and their families needs, expectations, autonomy, access to hospital support networks, communication, confidentiality, dignity, choice of provider and desire for prompt, timely care Subdimensions Mapped Onto CIHI s Cascaded Framework Conformity to processes of care Outcomes of processes of care Appropriateness of care Producing appropriate bundle of services given a patient s needs Producing maximum outputs for given inputs Hospital innovation and learning capacity Hospital staff orientation Responsive governance Ensuring appropriate discharge location Ensuring appropriate processes are enforced Patient safety Staff safety Environment safety (last two are included as staff orientation in Figure 4) Client orientation Respect for patients Access Source Canadian Institute for Health Information, 2013. 9

To produce a final cascaded hospital performance framework relating CIHI s Health System Performance Measurement Framework to the hospital performance dimensions, the four cascaded hospital quadrants outlined in Table 4 are mapped onto the four quadrants of the health system framework (Figure 4). The grey-shaded boxes indicate the key components of the health system framework, while the coloured boxes correspond to the Hospital Performance Framework, with each colour indicating which of the four quadrants it corresponds to. The cascaded framework illustrates how the first quadrant the social determinants of the community served by the hospital must be factored into the inputs and characteristics used in the production process of the hospitals. In particular, these determinants link to the responsive governance function of the hospital, which reflects the degree to which a hospital is responsive to community needs. As outlined in Table 4 and illustrated in Figure 4, this can be done by ensuring that appropriate processes are enforced within each hospital and that resources are allocated such that they reflect the needs of the community. The green boxes relate to the second quadrant of the cascaded framework, hospital inputs and characteristics, and to three dimensions outlined in the PATH framework in Table 3: efficiency, staff orientation and responsive governance. These actions represent all factors relating to providing physical and human resources (staff orientation), allocating hospital inputs (efficiency) and coordinating inputs across the organization and the community (responsive governance). Figure 4: Cascading Framework From Health System Performance to Hospital Performance Source Canadian Institute for Health Information, 2013. 10

Finally, the orange boxes represent the third and fourth quadrants of the cascaded framework, which correspond to the third quadrant of the health systems framework: health system outputs. Hospital outputs reflect the subset of health system outputs that can be produced within the hospital. They correspond to the PATH dimensions of safety, clinical effectiveness and patientcentredness (see Table 3). Finally, hospital outcomes represent the health system outputs that directly contribute to the attainment of the key health system outcomes. At the hospital level, these represent improving health protection and survival offered by hospitals, improving the patient experience with hospital services and improving the efficiency of hospitals. With regards to the efficiency of hospitals in particular, careful distinction should be made between technical and allocative efficiency. In the health services literature, technical efficiency refers to the question of how goods are produced given certain inputs, whereas allocative efficiency refers to the question of what outputs are produced and suggests that there is a unique point of production that maximizes societal values. It should also be noted that while technical efficiency should be used to assess all actors who use inputs to produce outputs, allocative efficiency can be influenced only by actors who have the power to make decisions regarding what to produce, and thus should be assessed for only those organizations. 11 Therefore, depending on the capabilities hospitals have to determine their own priorities and select what bundle of services to provide, it may or may not be meaningful to assess their allocative efficiency. Hospital Performance Framework As a final step, the cascaded framework can be used as a basis to produce the Hospital Performance Framework (Figure 5). The Hospital Performance Framework represented in Figure 5 considers the hospital production process as outlined in relation to the health system in Figure 4. The Hospital Performance Framework represents the hospital production process (the black square) that lies within the health system (the grey area) and the wider demographic, economic and political contexts. This representation suggests that hospital performance will be influenced by actions in other areas of the health system, as well as the social determinants of health and the extent to which these are addressed. For example, survival rates of a hospital may be lower if there is inadequate primary care in the health system and/or if there are unhealthy behaviours among the population. The boxes/structures represented within the black square represent the production process within a hospital; that is, they identify the inputs of hospital production as well as the outputs and outcomes they are intended to produce. 11

Figure 5: Hospital Performance Framework Source Canadian Institute for Health Information, 2013. Within the Hospital Performance Framework, the colours match those of the Health System Performance Measurement Framework, indicating that hospital inputs are a subset of health system inputs while hospital outputs and hospital outcomes are subsets of health system outputs. This reflects the point made above and highlighted in Table 2: hospital outcomes reflect the contribution hospitals make toward attaining the health system outcomes in the form of health system outputs. While hospital outcomes represent outputs at the systems level, they are important for the assessment of hospital performance as they signify the key goals for these meso-level organizations. For this reason, the three hospital outcomes (health survival, recovery and protection; positive patient experience; and hospital efficiency) are shaded in a darker colour. The main definitions of each of the inputs, outputs and outcomes are outlined in Table 4 and draw from the Health System Performance Measurement Framework and the PATH framework outlined previously. 12

Table 4: Dimensions of the Hospital Performance Framework Dimension Definition Example Indicators Exogenous Factors Social Determinants of Health Health System Hospital Inputs Responsive Governance Hospital Resources and Staff Orientation Efficient Allocation of Hospital Resources Social determinants of health represent the factors outside the health system that influence the health of a population. In this framework, these include genetic endowment, social position, life conditions and physical environment. All activities whose primary purpose is to promote, restore, and maintain health. 10 The degree to which a hospital is responsive to community needs, ensures care continuity and coordination, promotes health, is innovative and provides care to all citizens. Hospital resources refers to the amount of physical and human resources used to deliver patient care in hospital. Staff orientation refers to the degree to which hospital staff are appropriately qualified to deliver the required patient care, have the opportunity for continued learning and training, work in positively enabling conditions and are satisfied with their work. Efficient allocation of resources measures how resources are combined to produce health services to meet the population-based demands and needs of a society. Indicators on income, age, environment, education, behaviours and lifestyles should be used to adjust hospital outcome indicators. Indicators on the use of other areas in the health system (primary care, public health, rehabilitation, etc.) should be used to adjust hospital outcome indicators. Indicators are needed on hospital/primary care/public health integration and consideration of patient needs when making resource allocation decisions. Total beds staffed and in operation Total expenditures Administrative expense as a percentage of total expense Nursing inpatient services total worked hours per weighted case Diagnostic services total worked hours per weighted case Clinical laboratory total worked hours per weighted case Pharmacy total worked hours per weighted case 13

Table 4: Dimensions of the Hospital Performance Framework (cont d) Hospital Inputs (cont d) Ensuring Appropriate Processes of Care Hospital Innovation and Learning Capacity Hospital Outputs Access to Hospital Services Clinical Effectiveness This refers to the capacity of the hospital to continually adapt itself to meet the health needs of the population it services through innovation and learning and also by adjusting the allocation of resources across hospital services. Hospital innovation represents the implementation of an internally generated or borrowed idea whether pertaining to a product, device, system, process, policy, program or service that was new to the organization at the time of adoption. Learning capacity in the health system refers to the extent to which the system is skilled at creating, acquiring, and transferring knowledge, and at modifying its behaviour to reflect knowledge and insights. 1 Access to comprehensive hospital services corresponds to the range of hospital services available and the hospital s ability to meet the needs of the population or a particular patient without financial, organizational or geographical obstacles standing in the way of seeking or obtaining these services. When a hospital, in line with the current state of knowledge, appropriately and competently delivers clinical care or services to, and achieves the desired outcomes for, all patients likely to benefit most. Indicators are needed on the time taken to adopt best practice processes in hospitals (development of clinical guidelines, monitoring of processes, etc.). Indicators are needed on IT implementation in hospitals, knowledge transfer activities, quality improvement activities, performance measurement activities, etc. Time to see a physician in the emergency department (ED) by triage level Wait time in ED before being admitted Rate of transfers to another facility Number of days the ED was closed/ number of days the ED was over capacity Use of coronary angiography following acute myocardial infarction (AMI) Hip fracture surgical procedures performed within 48 hours across facilities 28-day readmission after AMI 28-day readmission after stroke 90-day readmission after hip replacement 90-day readmission after knee replacement 30-day overall readmission 30-day obstetric readmission 30-day readmission patients age 19 and younger 30-day surgical readmission 30-day medical readmission 14

Table 4: Dimensions of the Hospital Performance Framework (cont d) Hospital Outputs (cont d) Safety Patient-Centredness Coordination of Care Hospital Outcomes Patient Survival and Degree of Health Recovery and Health Protection Patient Experience With Hospital Services When a hospital has the appropriate structure and uses care delivery processes that measurably prevent or reduce harm or risk to the patient s health care providers and the environment. When a hospital places patients at the centre of care and service delivery by paying particular attention to patients and their families needs, expectations, autonomy, access to hospital support networks, communication, confidentiality, dignity, choice of provider and desire for prompt, timely care. The degree to which a hospital ensures that patients and clinicians have access to, and take into consideration, all required information on a patient s conditions and treatments to ensure that the patient receives appropriate health care services. The degree to which the hospital ensures that the continued needs of a patient are met upon discharge, including referral to community resources or partnership with other health care professionals. Patient survival is of overriding importance to most patients and can be measured over various periods appropriate to the medical condition. Degree of health or recovery achieved or retained at the peak or steady state normally includes dimensions such as freedom from disease and relevant aspects of functional status. Health protection refers to ensuring that a patient s health will be protected upon discharge through continuing integrated care and patient behaviours. Patient experience with hospital services is related to providing hospital care that is respectful of and responsive to individual patients preferences, needs and values, and the assurance that patient values guide all clinical decisions. In-hospital hip fracture in elderly (65+) patients Nursing-sensitive adverse events for medical patients Nursing-sensitive adverse events for surgical patients Obstetric trauma vaginal delivery with instrument Obstetric trauma vaginal delivery without instrument Harmful incidents (events resulting in patient harm and requiring acute care treatment, regardless of where the events occurred) Hospital-acquired infections (rates of sepsis, etc.) Rate of medical error (foreign object left in the body, medication incident, etc.) Restraint use for mental illness, as a measure of being treated humanely More indicators are needed in the responsiveness domains. Number of inpatient cases (separations) Average Resource Intensity Weight Average length of stay Percentage alternate level of care days Percentage alternate level of care cases Total beds staffed and in operation Hospital standardized mortality ratio 5-day in-hospital mortality following major surgery 30-day in-hospital mortality following AMI 30-day in-hospital mortality following stroke Patient experience survey indicators 15

Table 4: Dimensions of the Hospital Performance Framework (cont d) Hospital Outcomes (cont d) Hospital Efficiency Hospital efficiency measures the level of achievement of health protection, patient survival and patient experience given the resources used and compares this with the maximum attainable level. Cost per weighted case Absenteeism rates Other hospital efficiency indicators Source Canadian Institute for Health Information, 2013. The hospital inputs and outputs outlined in the Hospital Performance Framework draw heavily on the PATH framework, 3 the main difference being that the dimensions are separated into an input and output structure. On the input side, given the wider context of the health system, hospitals use responsive governance and the resources available to them to make resource allocation decisions and to adapt to the latest innovations. These actions allow them to ensure that the appropriate processes of care (both non-clinical and clinical processes) are being carried out within the hospital and enforced. Ensuring these inputs are in place should allow the five outputs identified to be attained: access to services, clinical effectiveness, safety, patient-centredness and coordination of care. All of these outputs refer to the degree to which successful transactions are achieved among patients and providers in the course of actual care delivery, taking into consideration patient and community needs. Attaining these outputs signifies a good likelihood that hospital outcomes, and in turn health system outputs and outcomes, will be achieved. Three hospital outcomes are identified, which represent subsets of the health system outputs necessary to achieve the three health system goals: improve health, improve responsiveness and improve value for money. As a hospital makes up only one entity in the health system, its outcomes cannot make up the entire health system outcome but merely contribute to its attainment. The full attainment of health system goals will depend on the contribution of all parts of the health system as well as their interaction. The first health system output identified relates to health improvement; it is threefold and draws upon Michael Porter s framework on Value in Heath Care, 12 as it takes into consideration the fact that different outcomes may be more meaningful for different patients. The first area identified is patient survival; this aspect is of overriding importance to most patients within a hospital and can be measured over various periods appropriate to the medical condition (for example, 30-day mortality for AMI or stroke). The second area identified is another important indicator the degree of health or recovery achieved or retained at the peak or steady state and may be more meaningful for older patients who weigh other outcomes more heavily. According to Porter, this area includes dimensions such as freedom from disease and relevant aspects of functional status. Finally, health protection refers to ensuring that a patient s health will be protected upon discharge through continuing integrated care and patient behaviours. This aspect is important as it refers to the sustainability of either of the previous two outcomes and the degree to which this can be achieved with good integration of the system across different areas. The second hospital outcome identified by the framework is positive patient experience with hospital services. Patient experience with hospital services is related to the provision of hospital care that is respectful of and responsive to individual patients preferences, needs and values, and the assurance that patient values guide all clinical decisions (Table 4). This hospital goal contributes to the health system goal of improving health system responsiveness. Finally, the third 16