Tim Freeman

Using performance indicators to improve health care quality in the public sector: a review of the literature

Given the increasing importance of performance indicators in current UK health policy, this paper provides a systematic review of empirical and theoretical writings concerning their use to improve health care quality. The paper outlines potential problems and explores how best to derive, implement and use performance indicator data, presenting results thematically. The two principal uses of indicator systems are as summative mechanisms for external accountability and verification, and as formative mechanisms for internal quality improvement. In the UK, the use of performance indicators in assurance and performance management systems has heavily influenced debate over their value. Major problems reported include the potential to undermine the conditions required for quality improvement, perverse incentives and the difficulty of using data to promote change. Technical problems include indicator selection; the availability, validity and reliability of data; confounding; and problems with robustness, sensitivity and specificity. Factors that help in the derivation, implementation and use of indicator systems include clear objectives, involvement of stakeholders in development, and use of soft data to aid interpretation.

Priority-setting and rationing in healthcare: Evidence from the English experience

In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching correct resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped.

Managing networks of twenty first century organisations

On this topic, Bob Hudson w1x previously observed that ‘‘It is now de riguer to talk of the shift from hierarchy to network in public sector governance « but what is often lacking is an understanding of how to analyse network governance’’. In literature, many commentators indeed point out that networks are unlike markets and hierarchies. However, the current authors argue that such forms are not necessarily distinctive and might be overly inclusive, whereas when looking at inter-organisational relations, networks do not necessarily form a distinct category (superior in terms of flexibility, trust and innovation); they might still derive from market relations or hierarchical regulation. For such reasons, the book highlights that in order to understand the relationship between network structure and organisational performance, it is ‘‘necessary to examine the biases that particular types of relations might have to support certain kinds of performance’’. A balanced account of inter-organisational relations is therefore provided and tested throughout the chapters with explanatory purposes.

Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research.

CONTEXTnRecurring problems with patient safety have led to a growing interest in helping hospitals governing bodies provide more effective oversight of the quality and safety of their services. National directives and initiatives emphasize the importance of action by boards, but the empirical basis for informing effective hospital board oversight has yet to receive full and careful review.nnnMETHODSnThis article presents a narrative review of empirical research to inform the debate about hospital boards oversight of quality and patient safety. A systematic and comprehensive search identified 122 papers for detailed review. Much of the empirical work appeared in the last ten years, is from the United States, and employs cross-sectional survey methods.nnnFINDINGSnRecent empirical studies linking board composition and processes with patient outcomes have found clear differences between high- and low-performing hospitals, highlighting the importance of strong and committed leadership that prioritizes quality and safety and sets clear and measurable goals for improvement. Effective oversight is also associated with well-informed and skilled board members. External factors (such as regulatory regimes and the publication of performance data) might also have a role in influencing boards, but detailed empirical work on these is scant.nnnCONCLUSIONSnHealth policy debates recognize the important role of hospital boards in overseeing patient quality and safety, and a growing body of empirical research has sought to elucidate that role. This review finds a number of areas of guidance that have some empirical support, but it also exposes the relatively inchoate nature of the field. Greater theoretical and methodological development is required if we are to secure more evidence-informed governance systems and practices that can contribute to safer care.

Performing Leadership: Towards a New Research Agenda in Leadership Studies?

The notion that leadership involves performance is not new, but there has been little detailed exploration of the implications of theories of performance for contemporary leadership practice. This article differentiates between leadership `is performance and leadership `as performance as one means of investigating contemporary leadership. We suggest that this distinction allows for more sustainable accounts of the relationships between leaders, followers and the institutional settings within which they are generated and, consequently, the spaces in which there is potential for change to occur. The article argues that such insights may be made by combining ideas derived from writers on performance studies and performativity with new-institutionalist theory, the latter emphasising the crucial role of context in shaping the behaviour of leaders, so that their agency is always situated in specific settings.

Measuring progress in clinical governance: assessing the reliability and validity of the Clinical Governance Climate Questionnaire

Despite a lack of conceptual clarity, the importance of cultural change to clinical governance is widely accepted. While generic measures of organizational performance, culture and climate are available, their relationship to clinical governance is unclear. Consequently, there is currently no valid and reliable measure of clinical governance climate. This study aimed to address the deficiency by reducing a pool of clinical governance climate indicators developed via previous qualitative research, describing a latent factor structure and assessing the internal consistency and external validity of the factor model. The resultant instrument, the Clinical Governance Climate Questionnaire (CGCQ), attained high internal consistency and external (discriminant and construct) validity in a study population of healthcare Trust staff. It consists of 60 items distributed across six sub-scales of clinical governance: planned and integrated quality improvement; proactive risk management; absence of unjust blame and punishment; working with colleagues; training and development; and organizational learning. The measure enables those charged with leading the clinical governance agenda in UK healthcare organizations to assess the progress of organizational development initiatives, highlighting areas requiring particular attention. They might also be of interest to those concerned about the negative unintended consequences of performance management.

Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.

Reflections on leadership and place

Drawing upon the preceding articles in this issue, we propose a multiple discourses approach to the study of contemporary leadership and place-shaping literatures with the intention of encouraging researchers, policy-makers and practitioners to engage more self-consciously with the discursive frames within which they work. We argue that this is no mere intellectual exercise, but is crucial for garnering and combining the fruits of work in the (hitherto) parallel fields of leadership and place-making, where theorising has been fragmented and underemphasised, respectively. The approach seeks to reveal the different ways that ‘place’ is constructed, surfacing the tacit assumptions and aspects of leadership of place invoked. In the second section, we identify schools of leadership theory that directly speak to the notion of place, and use these discursive assumptions to re-interrogate the case studies featured in the previous articles. Third, armed with this discursive framework and illuminated by episodes from these contemporary stories of leading in a variety of places, we offer some research pointers to take this immature and exciting field forward.

Disinvestment in health— the challenges facing general practitioner (GP) commissioners

The economic downturn is placing increasing pressure on the financing of health care. For many health care providers, this means difficult decisions need to be made over what will and will not be funded. The NHS has not typically been good at decommissioning and disinvesting in services. The recent proposed changes to the commissioning function will mean that clinicians will have a leading role in population-based priority-setting. This could well enhance the quest for legitimacy in relation to difficult resource allocation decisions. However, it is unlikely that GPs alone will be able to meet the challenges ahead, and reasonable disinvestment decisions will require GPs to engage with a number of stakeholders including government, interest groups and the wider civic society.

Resource scarcity and priority-setting: from management to leadership in the rationing of health care?

While continued interest in the application of priority-setting technologies is perhaps unsurprising in a time of austerity, they require sensitive implementation for their full potential benefits to be realized. This article looks at the role and value of leadership in addressing problems of a lack of perceived legitimacy and governance that have been raised in connection with the rationing enterprise. The potential and limitations of key leadership concepts such as ‘sense-making’ and ‘framing’ are explored, and notions of relational leadership and the importance of leading with political astuteness are discussed.