A Performance Measurement Framework for Canadian Hospitals ... · A Performance Measurement Framework for Canadian Hospitals, 2013 Clinical effectiveness refers to the process by

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Standards and Data Submission

A Performance Measurement Framework for Canadian Hospitals, 2013

Our VisionBetter data. Better decisions. Healthier Canadians.

Our MandateTo 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 ValuesRespect, 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

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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.

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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.

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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.

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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.

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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.

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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 countries3 and implemented in another eight countries in Europe.4

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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).

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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.

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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.

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Table 1: PATH Hospital Performance Dimensions

Performance Dimension Short Definition

Clinical Effectiveness 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

Efficiency Optimal use of inputs to yield maximal outputs or care services

Staff Orientation Appropriately qualified to deliver care, with opportunities for continued learning and training, positively enabling conditions and satisfaction with their work

Responsive Governance Responsive to community needs, ensuring continuity and coordination of care and the provision of care to all

Safety Structure and care delivery processes that prevent or reduce harm or risk to patients, care providers and the environment

Patient-Centredness 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

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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

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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

Health System Inputs and Characteristics Health System Outputs

Health System Outcomes

Structural factors influencing health

Biological factors Psychosocial and

behavioural factors Material factors

Leadership and governance

Health system resources

Efficient allocation of resources

Adjustment to population health needs

Health system innovation and learning capacity

Access Promotion and

prevention Efficiency and

effectiveness

Improve health status Improve

responsiveness Improve value

for money

Relationship Between Health System and Hospital Care

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 determine how many and what inputs are available for hospitals. Hospital inputs are a subset of health system inputs.

Health system outputs will influence patient need and the severity of hospital patients.* Hospital outputs are a subset of health system outputs.

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 outcomes represent a subset of health system outputs.

Hospital Care Social Determinants of Health

Hospital Inputs and Characteristics Hospital Outputs Hospital Outcomes

All of the above applied to the population the hospital is providing its services to

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).


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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.

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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 PATH Definition Subdimensions Mapped Onto CIHI’s Cascaded Framework

Clinical Effectiveness 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

Conformity to processes of care Outcomes of processes of care Appropriateness of care

Efficiency A hospital’s optimal use of inputs to yield maximal outputs, given its available resources

Producing appropriate bundle of services given a patient’s needs

Producing maximum outputs for given inputs

Staff Orientation 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

Hospital innovation and learning capacity

Hospital staff orientation

Responsive Governance

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

Responsive governance Ensuring appropriate

discharge location Ensuring appropriate processes

are enforced

Safety 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

Patient safety Staff safety Environment safety (last two are

included as “staff orientation” in Figure 4)

Patient-Centredness 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

Client orientation Respect for patients Access


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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


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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 patient-centredness (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.

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Figure 5: Hospital Performance Framework


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.

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Table 4: Dimensions of the Hospital Performance Framework

Dimension Definition Example Indicators

Exogenous Factors

Social Determinants of Health

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.

Indicators on income, age, environment, education, behaviours and lifestyles should be used to adjust hospital outcome indicators.

Health System “All activities whose primary purpose is to promote, restore, and maintain health.”10

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.

Hospital Inputs


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.

Indicators are needed on hospital/primary care/public health integration and consideration of patient needs when making resource allocation decisions.

Hospital Resources and Staff Orientation

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.

Total beds staffed and in operation Total expenditures

Efficient Allocation of Hospital Resources


Administrative expense as a percentageof 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

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Table 4: Dimensions of the Hospital Performance Framework (cont’d)

Hospital Inputs (cont’d)

Ensuring Appropriate Processes of Care

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.

Indicators are needed on the time taken to adopt best practice processes in hospitals (development of clinical guidelines, monitoring of processes, etc.).

Hospital Innovation and Learning Capacity

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

Indicators are needed on IT implementation in hospitals, knowledge transfer activities, quality improvement activities, performance measurement activities, etc.

Hospital Outputs

Access to Hospital Services

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.

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

Clinical Effectiveness 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.

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

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Hospital Outputs (cont’d)

Safety 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.

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.)

Patient-Centredness 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.

Restraint use for mental illness, as a measure of being treated humanely

More indicators are needed in the responsiveness domains.

Coordination of 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.

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 Outcomes

Patient Survival and Degree of Health Recovery and Health Protection

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.

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 With Hospital Services

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.

Patient experience survey indicators

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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


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

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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.

Finally, Table 4 relates each of the dimensions in the Hospital Performance Framework to indicators currently collected by the Canadian Hospital Reporting Project (CHRP). Where appropriate indicators did not already exist in the CHRP tool, a summary of the type of indicator necessary has been inserted instead.

Conclusions

Over the past decade, many performance assessment frameworks have been developed to assess hospital performance. While these frameworks have varied purposes, they all aim to provide a better understanding of the underlying structure of a hospital as well as to determine factors that drive its performance. However, for a hospital performance assessment tool to be of maximum use to all health system stakeholders, it is important that it be able to reflect the complexity and dynamic nature of hospital processes, and to consider the role of the hospital within the setting of the health system itself.

In an attempt to address these concerns, this paper proposes the new cascading Hospital Performance Framework, derived from CIHI’s Health System Performance Measurement Framework. The cascading nature of the Hospital Performance Framework from the original health systems framework allows a clearer illustration of the interdependencies between the health system dimensions and the hospital production process. This depiction may be useful for stakeholders, as it allows them to more clearly identify the areas where hospital performance can contribute to health system goals and also where allocation decisions at the system level can influence the hospital production process.

Given the amount of work that has already been undertaken in the area of conceptual approaches to hospital performance, it was decided that the gains from a creating a new framework have progressively decreased in proportion to the efforts required to undertake such a task. For this reason, the conceptualization of the key dimensions of hospital performance was based upon the WHO PATH framework, an internationally validated tool. Rather than focus on redefining the dimensions of hospital performance, this paper attempts to clarify areas where there are differences in matters of understanding and focus across the health system and hospital performance frameworks, resulting largely from the consideration of multiple levels of analysis. The cascaded framework attempts to link the performance goals and production process identified in the Health System Performance Measurement Framework to hospital goals and to the CHRP indicators currently being reported. This mapping exercise allows the construction of the separate Hospital Performance Framework, which allows the performance assessment of hospitals yet has strong links to the health system framework so that it is possible to clearly identify how these two levels of analysis are connected. Thus the Hospital Performance Framework should be able to support policy-makers to better interpret the actions and indicators relating to hospital performance within the broader health system context.

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Appendix A: Information Requirements for Stakeholders in Health Care Systems

Stakeholder Examples of Needs Data Requirements

Government To monitor population health To set health policy goals and priorities To be assured that regulatory procedures are

working properly To be assured that government finances are

used as intended To ensure appropriate information and

research functions are undertaken To monitor regulatory effectiveness

and efficiency

Information on performance at national and international levels

Information on access and equity of care Information on service utilization and

wait times Population health data

Regulators To protect patient safety and welfare To assure broader consumer protection To ensure the market is

functioning efficiently

Timely, reliable and continuous information on health system performance at aggregate and provider levels

Information on probity and efficiency of financial flows

Payers (Taxpayers and Members of Insurance Funds)

To ensure money is being spent effectively and in line with expectations

Aggregate, comparative performance measures

Information on productivity and cost-effectiveness

Information on access and equity of care

Purchaser Organizations

To ensure that the contracted providers deliver appropriate and cost-effective health services

Information on health needs and unmet needs

Information on patient experiences and patient satisfaction

Information on provider performance Information on the cost-effectiveness

of treatments Information on health outcomes

Provider Organizations

To monitor and improve existing services To assess local needs

Aggregate clinical performance data Information on patient experiences and

patient satisfaction Information on access and equity of care Information on utilization of service and

waiting times

Physicians To provide high-quality patient care To maintain and improve knowledge

and skills

Information on individual clinical performance State of the art medical knowledge Benchmarking performance information

Patients To make a choice of provider when in need

To have information on alternative treatments

Information on health care services available Information on treatment options Information on health outcomes

Citizens To be assured that appropriate services will be available when needed

To hold government and other elected officials to account

Broad trends in and comparisons of system performance at national and local levels across multiple domains of performance: access, effectiveness, safety and responsiveness

Source Smith PC, Mossialos E, Papanicolas I, Leatherman S. Performance Measurement for Health System Improvement. Cambridge, U.S.: Cambridge University Press; 2010.

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Appendix B: Key Concepts and Definitions From CIHI’s New Health System Performance Measurement Framework Key Concept Definition

Health System Outcomes

Health system outcomes correspond to the intrinsic goals of the health system. These outcomes are the improvement of the level and distribution of health in the population, the health system’s responsiveness to the needs and demands of Canadians and value for money to ensure health system sustainability.

Health Status Health status of individuals and the population covers three components: health conditions, health function and well-being.

Health Conditions Health conditions reflect the health problems and alterations of an individual that may lead to distress, interference with daily activities or contact with health services. They may be a disease (acute or chronic), disorder, injury or trauma, or they may reflect other health-related states such as pregnancy, aging, stress, a congenital anomaly or a genetic predisposition that can lead to death.

Health Function Health function corresponds to the general health status and functions of the population and is associated with the consequences of diseases, disorders, injuries and other health conditions. Health functions include body functions/structures (impairments), activities (activity limitations), participation (restrictions in participation) and life expectancy.

Well-Being Well-being reflects the level of physical, mental and social well-being of individuals and of populations as it relates to material conditions, quality of life and sustainability of well-being over time.

Health System Responsiveness

Health system responsiveness corresponds to the capacity of the health system to respond to the needs and expectations of the population. It also includes the element of trust in the health system, corresponding to the population’s confidence in the health system: that the system will be there for them and will respond to their needs.

Equity (in Health Status and System Responsiveness)

Equity (in health status and system responsiveness) is an overarching health system outcome that encompasses the equitable distribution of health status and system responsiveness across socio-economic groups—the equity of the health system. This implies that “everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.”13

Value for Money Value for money is related to the system outcomes of health status, system responsiveness and equity of the health system. It is a measure of the level of achievement of these three goals compared with the resources used.

Social Determinants of Health

Social determinants of health are represented in two levels: the structural and intermediary (biological, material, psychosocial and behavioural) factors that influence the health of a population and inequalities in health.

Structural Factors Influencing Health

Structural factors influencing health are those that shape individuals’ and families’ socio-economic position, such as income and social status, education and literacy, and gender and ethnicity. Taken together, the structural factors can expose individuals to and make them more vulnerable to unhealthy conditions.

Biological, Material, Psychosocial and Behavioural Factors

Biological, material, psychosocial and behavioural factors are collectively referred to as “intermediary determinants of health.” Biological factors include genes, aging processes and sex-linked biology. Material circumstances include characteristics of neighbourhoods, housing, working conditions and the physical environment. Psychosocial circumstances include stress, an individual’s sense of control and social support networks. Behavioural factors include such things as smoking, physical exercise, diet and nutrition. There are interrelationships among these intermediary factors, as there are between intermediary and structural factors influencing health.

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Key Concept Definition

Health System Outputs

Health system outputs are services delivered that result from activities undertaken by the organizations and individuals that are a part of the health system. The dimensions within the Health System Outputs quadrant describe the characteristics that contribute to the quality of the services. These characteristics apply to all services delivered by the health system, including public health and health promotion and disease prevention services delivered to populations, as well as services delivered to individuals, for example, hospital, physician, mental health or long-term care health services.

Access to Comprehensive, High-Quality Health Services

Access to comprehensive, high-quality health services corresponds to the range of health services available, including public health, health promotion and disease prevention services, and the ability to meet the needs of the population or an individual without time delay, financial, organizational or geographical obstacles standing in the way of seeking or obtaining health services. The attributes of “high-quality” health services are defined by the other dimensions in this quadrant and encompass the definition of quality developed by the Institute of Medicine.

Person-Centred Person-centred health services are respectful of and responsive to the preferences, needs and values of individuals and ensure that their preferences guide all clinical decisions. This also refers to the integration of and connections across health system structures, functions, sectors and professionals that put the individual receiving services and his or her informal caregivers at the centre of delivery and that support continuity of care.

Safe Safe health services are those that avoid injuries to individuals from the care that is intended to help them.

Appropriate and Effective

Appropriate and effective health services are provided based on scientific knowledge about who could benefit from the service, reducing the incidence, duration, intensity and consequences of health problems. Services are appropriate and effective when they are provided to all who could benefit and when person-centred decisions are made to refrain from providing services to those not likely to benefit.

Efficiently Delivered Efficiently delivered health services avoid waste, including waste of equipment, supplies, ideas and energy. This corresponds to the technical efficiency of the health system and refers to maximizing outputs (services) for a given level and mix of inputs (resources), or minimizing the inputs used to deliver a given level and mix of outputs.

Equity (in Health System Outputs)

Equity (in health system outputs) refers to the capacity of the health system to deliver comprehensive, high-quality outputs (services) to individuals and populations in an equitable way, without the imposition of financial or other barriers to receiving care that is person-centred, safe, appropriate and effective, and efficiently delivered.

Health System Inputs and Characteristics

Health system inputs and characteristics refer to the relatively stable characteristics of the health system, including the governance and leadership capacities in the system, the resources available for use, the distribution and allocation of those resources, the capacity to adjust and adapt to meet population health needs, and the innovation and learning capacities of the system.

Leadership and Governance

Leadership and governance involve ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system design and accountability.

Health System Resources

Health system resources are the financial, human, physical, technical and informational (including evidence and high-quality data) resources that are available to the health system.

Innovation 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 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

Efficient Allocation of Resources


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Key Concept Definition

Adjustment to Population Health Needs

Adjustment to population health needs refers to the capacity of the health system to continually adapt itself to meet the health needs of the population through innovation and learning and also by adjusting the allocation of resources.


25


Appendix C: Key Concepts and Definitions From the PATH Framework

Dimension Definition Subdimensions

Clinical Effectiveness

Clinical effectiveness is a performance dimension, wherein 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

Conformity to processes of care, outcomes of processes of care, appropriateness of care

Efficiency Efficiency is a hospital’s optimal use of inputs to yield maximal outputs, given its available resources

Appropriateness of services, inputs related to outputs of care, use of available technology for best possible care

Staff Orientation Staff orientation is 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

Practice environment, perspectives and recognition of individual needs, health promotion activities and safety initiatives, behavioural responses and health status


Responsive governance is 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 irrespective of racial, physical, cultural, social, demographic or economic characteristics

System/community integration, public health orientation

Safety Safety is the dimension of performance, wherein a hospital has the appropriate structure and uses care delivery processes that measurably prevent or reduce harm or risk to patients, health care providers and the environment, and which also promote the notion

Patient safety, staff safety, environment safety

Patient-Centredness

Patient-centredness is a dimension of performance wherein 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

Client orientation, respect for patients

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.

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References

1. Garvin DA., Edmondson AC., and Gino F., eds. Is yours a learning organization? Harvard Business Review. 2008;86 (3):109-116.

2. Papanicolas I, Smith PC. Frameworks for International Comparisons. Performance Comparisons for Health System Improvement. Maidenhead: Open University Press; 2013.

3. 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.

4. Veillard J, Schiotz M, Guisset AL, Brown ADB, Klazinga N: A qualitative evaluation of the implementation of the WHO Performance Assessment Tool for quality improvement in Hospitals (PATH) in eight European Countries. International Journal for Health Care Quality Assurance, Vol. 26, Issue 8, Nov 2013. In press.

5. Canadian Institute for Health Information (CIHI). Canadian health information roadmap initiative indicators framework. Ottawa, ON: Canadian Institute for Health Information; 1999.

6. Arah OA, Klazinga NS, Delnoji DM, Ten AHA, Asbroek T, Custers T. Conceptual frameworks for health systems performance: A quest for effectiveness, quality, and improvement. International Journal for Quality in Health Care. 2003; 15: 377-398.

7. Canadian Institute for Health Information (CIHI). A Performance Measurement Framework for the Canadian Health System. Ottawa, ON: Canadian Institute for Health Information; 2012.

8. Cameron KS, Whetten DA. Organizational effectiveness: A comparison of multiple models. Orlando, FL: Academic Press; 1983.

9. Sicotte C, Champagne F, Contandriopoulos AP, et al. A conceptual framework for health care organizations’ performance. Health Services Management Research.1998; 11; 24-43.

10. Murray C and Frank J, eds. A framework for assessing the performance of health systems. Bulletin of the World Health Organization. 2000;78(6)

11. Papanicolas I, Smith PC, Culyer T, Tsuchiya A. The theory of systems level efficiency in health care. Encyclopedia of Health Economics. Elsevier. In press

12. Porter M. What is value in health care? New England Journal of Medicine. 2010; 363; 2477-2481.

13. Whitehead M. The Concepts and Principles of Equity and Health. Copenhagen: World Health Organization, Regional Office for Europe; 1990.

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Canadian Institute for Health Information. A Performance Measurement Framework

for Canadian Hospitals, 2013. Ottawa, ON: CIHI; 2013.

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