Performance management in healthcare: a critical analysis

Putting the pieces together: towards an integrative framework for healthcare performance

PURPOSE

In the past few decades, performance measuring systems have become important managerial tools for healthcare organizations. Healthcare performance metrics are a useful tool in understanding how healthcare organizations achieve their goals while satisfying the needs of their patients and conforming to national and international standards. Various efforts have been made to assess healthcare performance. Most of these measures are focused on a single perspective or developed by a single source to meet management and strategic objectives on time.

DESIGN/METHODOLOGY/APPROACH

We develop a review of the literature to shed light on the measures used to assess performance in the healthcare sector at various points in time, as well as to establish a thorough understanding of healthcare performance measurement.

FINDINGS

Developing real-time digital traceability of metrics and an integrative perspective that increases the actionability of information acquired is an attractive potential made possible by the introduction of new technologies and the digitization of data.

ORIGINALITY/VALUE

We conclude that a proper measurement system should be one to combine patient, physician, non-medical staff and system perspective, which will further facilitate the assessment of healthcare performance and the comparative function.

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review

BACKGROUND

Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes.

METHODS

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views.

RESULTS

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost-benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary.

CONCLUSION

Our analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs.

TRIAL REGISTRATION

Review registration: PROSPERO; CRD42021236948.

The development of nurse prescribing in mental health services: Outcomes from five national surveys 2004-2019

AIM

This study aimed to explore data from national surveys of nurse prescribing in England's National Health Service mental health services.

BACKGROUND

Nurse prescribing is increasing worldwide. Reports describing long-term developments after implementation are rare.

METHODS

Five surveys were distributed to all mental health organisations between 2004 and 2019.

RESULTS

Response rates increased from 54% (n = 45/83) in 2004 to 79% (n = 42/53) in 2019. The estimated proportion of mental health nurses who were prescribers increased to 4.3% by 2019. Distribution between clinical practice areas did not change significantly over time, with the largest numbers in community mental health teams. The proportion of nurse prescribers actively prescribing increased from 76.4% in 2014 to 87.8% in 2019. Independent prescribing became the predominant approach, with supplementary prescribing rarely used as the sole model within organisations. The scale of implementation varied markedly between organisations.

CONCLUSIONS

Although nurse prescribing in mental health services has grown over time, growth has slowed and is variable at local level.

IMPLICATIONS FOR NURSING MANAGEMENT

Organisations considering the introduction or growth of nurse prescribing should note the evidenced preference for an independent prescribing model to date and consider how to avoid unwarranted variation in nurse prescriber role distribution.

Individual-Level Factors are Significantly More Predictive of Employee Innovativeness Than Job-Specific or Organization-Level Factors: Results From a Quantitative Study of Health Professionals

Individual innovativeness is particularly indispensable among health professionals. The healthcare environment is complex and its knowledge workers must continually adapt to change and be comfortable with ambiguity. The objective of this study was to determine the relative importance of individual, job-specific, and organizational factors on innovative output of health professionals. Employed Canadian Registered Dietitians (n = 237) completed an online survey incorporating relevant validated tools, including the 10-item Big Five Inventory and the Alberta Context Tool. Factors were classified by level and introduced in blocks to a multivariate linear regression model, with the outcome of self-reported innovative output. Factors included in the model explained 44% of variation in self-reported innovative output. Although all blocks contributed significantly to the model, minimal variation was explained by factors at the job-specific (4%) and organizational levels (4%). Factors at the individual level most predictive of innovative output were role innovation, the personality trait of conscientiousness and voluntary membership in a professional association. To encourage employee innovativeness, health administrators, and managers of health professionals should consider how best to incorporate screens for individual-level indicators of innovative output (eg, personality tests) in their institutional hiring and selection processes.

Performance management in complex adaptive systems: a conceptual framework for health systems

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

[Identifying indicators of good practice in clinical and healthcare management]

OBJECTIVE

To identify good practices in order to develop and implement indicators of health outcomes for clinical and healthcare management, as well as the characteristics for an indicator to be considered adequate.

METHODOLOGY

A scoping review was performed, with the following phases: 1) Search and identification of bibliography. 2) Selection of relevant documents. Including those studies that discussed issues related to good practices for the use of health indicators in the management field. Those published in a language other than English or Spanish or before 2006 were excluded. 3) Analysis and extraction of information. 4) Consultation with stakeholders, using a qualitative methodology through Concept Mapping, with the participation of 40 experts (decision-makers, scientific societies, and health professionals). The data collection process included an inductive and structured procedure, with prioritisation of ideas grouped into clusters, according to feasibility and importance criteria (0-10 scale).

RESULTS

Good practices identified 2 levels: 1) macro-management: Define a framework for the evaluation of indicators and establish a benchmark of indicators. 2) meso-management: Establish indicators according to evidence and expert consensus, taking into account priority areas and topics, testing before final use, and communicate results adequately. The characteristics of a suitable indicator are: 1) Approach of an important issue, 2) Scientific validity, 3) Possibility of measurement with reliable data, 4) Meaning of useful and applicable measurement, and 5) Wide scope.

CONCLUSIONS

The best practices for the use of indicators in clinical and healthcare management can make it easier to monitor performance and accountability, as well as to support the decision-making addressed at the development of initiatives for quality improvement.

COLLABORATE©, Part IV: Ramping Up Competency-Based Performance Management

PURPOSE/OBJECTIVES

The purpose of this fourth part of the COLLABORATE© article series provides an expansion and application of previously presented concepts pertaining to the COLLABORATE paradigm of professional case management practice. The model is built upon a value-driven foundation that: PRIMARY PRACTICE SETTING(S):: Applicable to all health care sectors where case management is practiced.

FINDINGS/CONCLUSIONS

As an industry, health care continues to evolve. Terrain shifts and new influences continually surface to challenge professional case management practice. The need for top-performing and nimble professionals who are knowledgeable and proficient in the workplace continues to challenge human resource departments. In addition to care setting knowledge, professional case managers must continually invest in their practice competence toolbox to grow skills and abilities that transcend policies and processes. These individuals demonstrate agility in framing (and reframing) their professional practice to facilitate the best possible outcomes for their clients. Therefore, the continued emphasis on practice competence conveyed through the performance management cycle is an essential ingredient to performance management focused on customer service excellence and organizational improvement.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Professional case management transcends professional disciplines, educational levels, and practice settings. Business objectives continue to drive work process and priorities in many practice settings. However, competencies that align with regulatory and accreditation requirements should be the critical driver for consistent, high-quality case management practice. Although there is inherent value in what various disciplines bring to the table, this advanced model unifies behind case management's unique, strengths-based identity instead of continuing to align within traditional divisions (e.g., discipline, work setting, population served). This model fosters case management's expanding career advancement opportunities.