Performance refers to the activities carried out by a unit (be it an individual, team, department or division) of an organization intended to accomplish some desired results or goals. Measuring the performance of the unit is useful for helping the unit or organization determine how successful it is in making progress towards its goals. Performance measurement is intrinsically related to organizational goals; sound performance measures simply cannot be specified unless goals have been clearly determined. If you are uncertain where you are going, you simply cannot know whether you have made progress.

In healthcare, there are 6 generally recognized goals. These are healthcare should be safe, effective, patient-centered, timely, efficient, and equitable. Performance measures (also known as performance indicator or KPI) are then selected to help track progress in accomplishing one or more of these 6 goals in a specific clinical or therapy area. For the first 4 healthcare goals (safe, effective, patient-centered, timely), three broad group of performance measures are common used in healthcare:

a Measures of patient perspectives on care include patient assessment and satisfaction with their access to and interactions with the care delivery system (e.g., waiting times, information received from providers, choice of providers).
b Measures of clinical quality are specific quantitative indicators to identify whether the care provided conforms to the established treatment and care processes. Clinical quality measures consist of a descriptive statement or indicator (e.g., the rate of beta blocker usage after heart attack),
c Measures of patient outcomes include mortality (death), morbidity (complications), and physical and mental functioning.

Unfortunately measuring the performance of healthcare is not a straightforward matter. We are just now beginning to make an effort to measure the performance of healthcare in Malaysia. Our everyday experience in evaluating the performance of other services (such as travel, hotel, meals, haircut etc) to inform our purchasing decisions may not translate easily to healthcare for several reasons:

    • Healthcare is a much more complex service compare with the everyday services like the travel, hotel, restaurant meals or haircut that we consume. We often cannot just rely on our feelings (or symptoms) to evaluate the service outcome, like we do with meals (taste), travel (on time), hotel (comfort) or haircut (look). In many instances, use of a health service is a one-time experience such as cancer treatment, heart surgery or kidney transplant; we have little chance to use our past consumption experience to guide our future choices of service providers.
    • Healthcare is also not a single discrete service at all (for convenience we refer to them collectively as healthcare) but a range of specific services for specific diseases or medical conditions. The services are provided by a range of medical specialists (who have to spend many years acquiring the necessary skills) employing highly sophisticated technology. So many of us quite naturally do not think we are competent to decide for ourselves and simply defer to their professional opinion. But that doesn't mean the performance of healthcare cannot be measured, only the measurement methodology is more complex and experts exists to conduct performance measurement. Just as you may not feel competent to assess the performance of modern cars and so rely on consumer reports written by auto experts to help you.
    • Healthcare is also peculiar in that often there is no guarantee of a positive outcome. You are practically guaranteed to get a meal in a restaurant or reach your destination when travelling by air even if you may not quite enjoy the experience but in healthcare nobody will guarantee you will avoid death much less that you will recover from your illness. Adding to the frustration, it is often hard to tell whether the patient died regardless of what anybody could have done or that the death was the result of medical errors (In case you think hospital is a pretty safe place where errors are rare, you should quickly disabuse yourself of that notion. One in ten people admitted into hospital is harmed by medical error in advanced countries, the risk is likely much higher here though as usual this has never been routinely measured in Malaysia; you are 3000 times moiré likely to be harmed when receiving healthcare than when travelling in an aircraft).
    • The comparison with traveling in an aircraft marks another peculiarity with the healthcare industry. Like airline or nuclear industry, healthcare is a high risk industry. But unlike airline or nuclear industry, the performance of healthcare industry, at least in Malaysia, were never subject to surveillance, and health professionals unlike aircraft pilot were also free from performance monitoring. We are all simply told to take it on trust that health professionals will always do their best for you and I and perform superbly at all time.
    • But we do know healthcare is fraught with perverse incentive. If a patient had complications as a result of medical error, the doctor and hospital actually make more money from your prolonged stay in the hospital. No I am saying anybody does that deliberately but this is nonetheless perverse . We also know doctors do over-investigate or over-treat to boost their incomes; they do charge us more if we are covered by insurance; they do game the system to claim more fees from insurance companies. In short they do behave much like other self-serving humans out to maximize their profit, which really should not surprise anyone. So for consumers and purchasers of healthcare, we should not take in everything on good faith. By all means trust doctors and hospitals, but do insist on verifying their performance.
  • The most common questions asked of any doctors in any causal encounter are:

    • I have this symptom, can you recommend whom I should see?
    • I have heart disease, can you recommend a cardiologist?
    • I am seeing this doctor for my heart condition, is he any good? Can you recommend someone better?
    This tells us there is a huge pent-up demand for more information on healthcare; after all we all will need to use health service at some point in our life.

    Information on the availability of health services and their performance should be more widely available, just like for any other consumer services and goods. Unfortunately for us, the only way we could get such information is through words of mouth, in other words, the layman's opinion uninformed by hard data and the rigorous methods of healthcare performance measurement. Citizens of advanced countries are more fortunate; they have ready access to such information, Just check out these websites:

    • http://www.consumerreports.org/health/home.htm
    • http://www.healthgrades.com/
    • http://www.whynotthebest.org/

    For health professional, there is simply no better reason for measuring performance than assuring your patients that you are truly doing your best for them.

    I am sure you will also feel reassured, perhaps even a little self satisfaction and considerable professional pride, to find that that your performance is comparable to

    the benchmark set for your field. Provided of course a robust and scientifically sound method is available to measure your performance as a health professional. Sign up today.

    Like for health professional, there is simply no better reason for measuring performance than assuring your customers that they have made the right choice in coming to your facility.

    Management is also entitled to celebrate their achievement in performing to, if not exceeding, industry benchmark. You may even begin to demand that health insurance company pay your facility a premium for its performance. This will also certainly cause your competitors to start running for cover. Always compete on performance, not on price; Up the game, not drop the price please.

    Sign up today

    If you are the HR manager deciding on which healthcare providers to include in your company's panel, or the insurance manager deciding on which health plans to cover, about time you start insisting on performance data from healthcare providers. Always pay for performance, not just the cheapest available healthcare.

    To all the long suffering taxpayers in Malaysia, about time too we tell our public health service managers to demonstrate performance; show us some serious values for the billions in taxpayers' money we have poured into public health services in this country. Write to your MP or PEMANDU now, make your voice heard.

    Credible performance measurement must meet several best practice requirements:

    a. It should be conducted by individuals who are qualified by education, training, and experience to perform the task.
    b The methodology must be scientifically sound, be subjected to independent review and approval by a relevant authority.
    c It should be conducted by a third party independent of the organization whose performance is being measured.
    d It must have a real basis in real data, not based on opinion, assertion or conjecture
    e The data in turn must be subjected to QA (is the data accurate?) and independent data audit (did anybody tamper with the data to make the organization looks good?)
    f The performance result (which is a number or statistic calculated from the data) must be risk-adjusted. That means the performance results need to be statistically modified to take into account those elements of the patient population that affect results but are out of the control of the organization.
    g The result should be published so that all may critique it and judge for themselves, and actually make use of the information if in our assessment the result is credible.

    Public healthcare KPIs often fail meet these requirements:

    • The people conducting it are probably largely untrained and unfamiliar with this. We don't know who they are, nobody has ever seen their CVs to verify that they are suitably qualified to perform such work; the methodology (measurement protocol) has never been published, never mind been independently reviewed and approved by others.
    • Believe or not, public healthcare KPIs are usually based entirely on self-reporting by the institution whose performance is being measured; they are without basis in real data. For example, say a hospital is reported to have a post-operative death rate (a common KPI for surgery) of 5%. The 5% figure could be derived in 2 ways. (1) Ask the hospital to report the number of operations it had performed and number of deaths post-op, divide the 2 numbers to get 5%. This is self-reporting. (2) Collect real data on individual patients undergoing operations and follow them up to find out the number of deaths. Then statistically estimate the 5% from the data collected.
    • Even when some real data is collected, there is usually no data QA (is the data accurate?) never mind subjecting the data to audit by an independent third party (did anybody tamper with the data to make it looks good?).
    • Performance results are almost certainly not risk adjusted.
    • Finally, for some reasons, the performance results are rarely published. Try googling it and see if you could find anything. What is the point of measuring performance if the public never get to see the results?

    After a client has made a commitment to embark on healthcare performance measurement, getting this up and going is a standard 4-step process as follows:

    • Step 1: We work with our clients and the relevant health professionals to identify one or more therapy or clinical areas to target for measurement, then set goals and performance measures for the selected areas.
    • Step 2: Next we begin to organize for data collection and reporting, with the help of various tools such as Data Abstraction Form, web based tools like HPMRS www.hpmrs.com.my ). the collected data are subject to routine data management including QA and independent audit by a third party A protocol is developed to document the decisions made in Step 1 and to serve as a manual for Step 2. The protocol needs to be submitted for review and approval by a relevant authority.
    • Step 3: Performance results are published in independent website such as HPMRS www.hpmrs.com.my, journal and mass media to enable users (consumers, patients, purchasers, regulators and referring clinicians) to access these information, and to which our clients reference their results.
    • Step 4:Finally, We assist our clients in interpreting the performance results, and in using them as a guide to action and for accountability, quality improvement and advocacy