In the last decade, there has been substantial progress in the measurement and reporting of healthcare performance. Many stakeholders, especially policymakers, health care payers, healthcare -advocacy and consumer groups are pressing for the increased use of performance measurement and reporting for purposes of accountability and population health, or to promote improvements in the delivery of care.

The trend is particularly marked in the US, where almost all healthcare providers participated in such performance measurement and reporting program [1]. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) launched the first national program in the US for the measurement of hospital performance in 1998. Since 2002, all hospitals accredited by the Joint Commission were required to collect and report data on performance [2] . In 2004, the Centers for Medicare and Medicaid Services (CMS) the largest payer for healthcare in the US, began financially penalizing US hospitals that did not report to the CMS the same performance data they collected for the Joint Commission, and in 2005, the CMS began its own public reporting [3].

In 2006, the Institute of Medicine published a highly influential report, Performance Measurement: Accelerating Improvement, which advocated strongly for performance measurement as a central tenet of US health care reform [4] .

Another watershed event occurred in 2010 when the Consumers Union (publisher of Consumer Reports) reported the results of coronary-artery bypass grafting (CABG) procedures at 221 U.S. cardiac surgery programs [5,6] . The reported ratings derive from a registry developed by the Society of Thoracic Surgeons (STS) in 1989. More than 90% of the approximately 1100 U.S. cardiac surgery programs participate in the registry. Registry data are collected from patients' charts and include key outcomes such as complications and death, the severity of preoperative illness, coexisting conditions, surgical technique, and medications. The data-collection and auditing methods, specifications of the measures, and statistical approaches have evolved over the course of two decades and reflect a substantial commitment by US cardiac surgeons and their leadership [7,8].

Many other countries have followed US's footstep and embraced this performance measurement paradigm. In the UK, the NHS has embarked on a Modernization Program which has developed several National Service Frameworks that specify goals, benchmarks and performance measures for targeted clinical areas [9]. In Australia, a Council for Safety and Quality in Healthcare was established in 2000 which has led to a groundswell of projects implementing performance measurement and reporting [10].

In Malaysia, the government has recently unveiled a Government Transformation Programme (GTP) known as the National Key Results Areas (NKRA) which includes improving people's quality of life, eradicating corruption, reducing crime rate, addressing poverty. As part of this program, the government has introduced Key Performance Indicators (KPI) to measure the performance level of government services. The Performance Management and Delivery Unit (Pemandu) in the Prime Minister's Department was formed in September 2009 to oversee the implementation and assess the progress of the GTP [11]. However, this has yet to impact on the public health services where performance measurement and reporting activity remains undeveloped. Similarly in the private healthcare sector, while financial performance measures are well established and routinely reported, robust healthcare performance measures that reflect the core business of the healthcare industry are practically non-existent.

Not surprisingly robust and user friendly program to enable healthcare performance measurement and reporting in Malaysia is still lacking. We have therefore developed the Healthcare Performance Measurement and Reporting System, HPMRS in short, to fill this gap in our healthcare sector. The HPMRS Protocol of the HPMRS program has been reviewed and approved by the MOH's Research & Ethics Committee. All interested Clinical and Healthcare provider groups are welcome to sign up.

Healthcare Performance Measurement and Reporting system or program should be designed to serve three broad purposes [4]:

Many stakeholders make important decisions that motivate or influence care delivery. Purchasers and consumers make decisions about the selection of health plans, providers, and treatment options; clinicians about the referral of patients to specialists, hospitals, and other providers; public- and private-sector oversight organizations about licensure, accreditation, board certification, and recognition awards; and purchasers/healthcare payers about which providers to include in their networks. To this end, healthcare performance information should be available to assist these stakeholders in making informed choices about providers.

Quality improvement
"You cannot improve what you cannot measure" is a well known truism. Stakeholders engaged in the delivery of health care services need information they can act upon to improve the quality of those services. Clinicians need performance data to support ongoing quality improvement. Health care administrators and managers and the members of their governing boards need performance data to support efforts directed at the redesign of care processes and the operation of systems to support care delivery.

Population health
The health care delivery system is one of many factors that can influence the health of a population. A well-functioning performance measurement and reporting system should provide information to support the broad range of public policy decisions that influence population health and ultimately the need for health care services.

The objective of the HPMRS is to establish a healthcare performance measurement and reporting system to meet the needs of the Malaysian healthcare system.
Healthcare system has six aims as articulated in the Institute of Medicine's Quality Chasm report [12]. These are healthcare should be safe, effective, patient-centered, timely, efficient, and equitable.

To this end, the program shall:

  • Adopt standardized performance metrics that are aligned with aims of healthcare system. The scope of the measurement shall include:
    a. Measure of patient's perception of care
    b. Measure of patient safety
    c. Measure of clinical effectiveness
    d. Measure of timeliness of clinical care
  • Develop and evaluate new measures to address current gaps in performance measurement in Malaysian healthcare.
  • Design and implement the required data collection, validation, and aggregation processes to support healthcare performance measurement for Malaysian healthcare.
  • Establish public reporting methods responsive to the needs of all stakeholders.
  • Investigate key methodological issues (such as risk adjustment method, influence of small sample size, weighting of elements of composite measures) surrounding performance measurement so as to enhance the accuracy and integrity of the data obtained.

Healthcare is highly complex and heterogeneous and will require multiple methods for assessing its performance.
Selection of a specific clinical or therapy area to be targeted for performance measurement and reporting shall be guided by consideration of the performance improvement goals of the therapy areas and by 3 specific criteria which are (1) Impact, (2) Improvability and (3) Inclusiveness.

Within the selected therapy areas, extant performance measures will be identified and implemented and, when they are absent, development and testing of additional measures, or improvement of the evidence base from which potential measures could be drawn, would be initiated.

Adoption of extant measures should be guided as follows [4]:

  • Measures currently being used for public reporting, pay-for-performance, or quality improvement efforts at the national or regional level;
  • Measures recognized by leading national stakeholder groups; and
  • Measures whose owner had a rigorous process in place for assessing validity and reliability, as well as a mechanism for updating or retiring measures

The design of all performance measure must adhere with 5 criteria, viz (1) Scientifically Sound, (2) Feasible, (3) Importance, (4) Alignment and (5) Comprehensiveness. The sub module has details on the definition of the performance measures for each individual therapy areas and specific health services covered by this protocol

The required data elements for the selected performance measures shall be defined and specified by sponsor designated CRO or vendor company. On this basis, the designated CRO or vendor company will design and develop the data capture instrument, including eCRF and paper DAF and the supporting information infrastructure.

Data Quality assurance (QA) is essential in the conduct of performance measurement, and will be effected through several mechanisms. No less essential is the auditing of the collected data and analytic methods prior to reporting the performance results

Performance results will be published and disseminated through HPMRS website, medical journal and mass media to enable users (consumers, patients, purchasers, regulators and referring clinicians) to access these information, and to which healthcare providers whose performance are measured may reference their results.

We encourage the use of data collected by the HPMRS for research and other purposes. To this end, public-use data and associated documentation will be made available for download by the public at HPMRS website.

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