Missing the target on health care performance?
Setting targets has long been a mechanism in industrial psychology to motivate managers and workers to achieve specific organizational objectives. In the last decade, targets have become important methods of driving performance improvement in health care. However, deciding where and when to set targets is a challenge facing health care decision makers.
Politics of performance targets in Alberta
Alberta Health Services (AHS) has been releasing quarterly performance reports, which include updates on provincially-established targets, since September 2009. Chris Eagle, past AHS CEO noted in 2011 that health care performance targets have been set to be “intentionally ambitious and aggressive”. However, the past two quarterly reports – for September and December 2013 – have not been posted.
Last month AHS made headlines after posting, and then within hours removing, an ‘Annual Report on Performance’ which included revised targets for 15 performance measures of the health care system, and fewer measures than previous quarterly performance reports.
The deleted report noted that “the targets associated with each measure represent a goal and standard to be achieved over time.” When pressed by media about why the report was taken down, AHS issued a statement noting that the targets were still in draft format.
Raj Sherman, Liberal opposition leader and emergency medicine physician says that the targets have been “watered down” from their initial goals. For example, the initial emergency department wait time target for patients presenting with urgent needs was that they would be admitted or discharged within 8 hours of arrival. This target was revised to 19 hours in the most recent report.
Sherman said targets were scaled back to achieve political aims, “they want a political win by saying they’ve achieved their target.”
Establishing health care performance targets must be done carefully and cautiously. Targets play an important role in highlighting key policy goals and helping to motivate organizations and providers to achieve these goals. However, experts warn that “careless target setting” based on poor data or unrealistic expectations can be discouraging and stressful to the organizations and staff aiming to achieve them.
Bill Ghali, physician and director of the University of Calgary Institute for Population and Public Health, says “setting targets can be a challenge because there is always a question of feasibility within a context.” Ghali notes that for emergency department waits, “no one person in the system can in isolation tackle the target.” He emphasizes that reducing emergency department waits is often beyond the control of emergency departments and hospitals, and is connected to availability of primary care and community-based care after hospital discharge.
An overview of target setting in health care
The World Health Organization describes targets as incentive mechanisms where an “objective to be met in the future” is established. Incentives for organizations to meet targets can include carrots or sticks – for example, governments can provide organizations with extra funding to dedicate more resources, such as staff or operating room time, to meet targets. In contrast, if organizations don’t meet targets, money can be clawed back or senior executives can risk losing their jobs, or portions of their pay.
Another incentive can be reputational, where organizational achievement of targets are publicly reported, an approach described as “naming and shaming”. An often referenced example of this is the star rating system in the United Kingdom’s National Health Service (NHS). From 2001 to 2004 a system was put in place where organizations were rated on a scale of 0 to 3 stars based on their achievement of an identified set of ‘key targets’. Organizations with high scores received public praise as well as additional funds to target towards priorities determined internally.
The star rating system resulted in dramatic improvements in performance around key targets, and reduced emergency department and elective surgery wait times. However, experts have also pointed out that organizations’ focus on meeting targets came at a cost – as some falsified data, or neglected areas of patient care not associated with targets.
This led to public debate in the United Kingdom around whether targets did more harm than good in the NHS. Those who support targets say that they set forth patient and provider expectations around “what we ought to expect from a modern, well funded NHS”. However, those who are opposed say that a focus on meeting measures takes away from patient care, arguing “targets suit politicians, not patients.”
Target setting in Ontario to improve performance
One high profile example of using targets to achieve health system objectives in Ontario is the Wait Times Strategy. Starting in 2004, the Ministry of Health and Long-Term Care committed to reducing wait times for selected diagnostic procedures and surgeries. The Ontario Wait Times Strategy provided financial incentives for hospitals to help meet these targets.
Alan Hudson, a retired neurosurgeon and past Ontario Wait Time Strategy Lead reflected on the use of setting targets to reduce wait times. “Targets are not perfect but worked perfectly well for the wait times project” he says. Though Hudson notes, referring in part to the United Kingdom experience, that “the downside of targets is that people work to the targets and may neglect other areas where there are no targets or incentives.”
Since its’ inception, the Ontario Wait Time Strategy has expanded to include all surgeries done in the province, as well as wait times across Ontario’s emergency departments. This strategy includes public reporting of wait times by hospitals, and the establishment of targets for these waits.
In addition to targets set at the provincial level, the 2010 Excellent Care for All Act mandates hospitals to develop annual Quality Improvement Plans (QIP) which set forth indicators of organizational performance, as well as targets. While the Ontario Ministry of Health and Long-Term Care suggests that QIPs should include areas that are linked to provincial priorities, hospitals use their own discretion to choose indicators and develop targets. The QIP Guidance Document, available on the Ministry of Health and Long-Term Care website, notes that targets should “represent what the organization aspires to, first and foremost.”
Hospitals are required by the Excellent Care for All Act to make QIPs publicly available, and are accountable to their boards of directors to meet targets set forth in QIPs. However, QIPs are currently documents aimed at internal quality improvement and targets are not formally shared or compared between hospitals. There are also no Ministry of Health and Long-Term Care financial or policy incentives tied to these targets.
Jeremy Veillard, Vice President of Performance Research and Analysis at the Canadian Institute of Health Information highlights inconsistencies across Ontario when it comes to QIP targets. “In some cases you’ll have leaders putting in place stretch targets, and using the target as a tool for improvement” says Veillard. However, he also points out that “strategies vary between hospitals with some not wanting to put in place stretch targets, and then be accountable for them.”
Target mania, indicator overload
Leslee Thompson, CEO of the Kingston General Hospital, argues that while setting targets is an important mechanism for accountability between provincial ministries of health and hospitals, sometimes “we get too focused on the numbers in isolation.”
Thompson says Ontario is deep in “target mania” where pressure to achieve targets can be discouraging for staff and organizations . She says that in her experience as a hospital leader “accountability systems do not rest only with performance measurement and target setting.”
Experts like Michael Schull, CEO of the Institute for Clinical and Evaluative Sciences, agree with Thompson saying “measurement is required, but not sufficient to bring about change to health care performance.” Schull says that while “you need to measure to know that you are improving,” more than measurement is needed to improve. Schull points to emergency department waits, which are impacted by many factors outside emergency departments, such as the availability of timely primary care. “Measurement won’t solve fundamental problems around health care integration” he says.
Thompson also points out that many targets set for hospital performance are indicators impacted by factors beyond a hospital’s four walls. This includes indicators like readmission rates, and alternate level of care. “As a hospital on your own you can’t influence all the things that you need to do. You can contribute, but you can’t move the needle on your own” she says.
Health Quality Ontario is the government agency to which hospitals submit QIPs. It is currently in the midst of developing a strategy known as the ‘Common Quality Agenda’ for performance measurement and target setting in the province. This strategy has stated goals of focusing on “a small number of priority areas” and to “improve quality through partnership.” Whether this initiative will help to reduce ‘target mania’ remains to be seen.
Bill Ghali emphasizes that target-setting and performance measurement is essential to ensuring accountability for health care. He says “it is untenable to have our system be in the dark about performance.” However, Ghali acknowledges that the “political climate around performance measurement” and target setting is a challenge.
Judging from the recent experiences in Alberta and Ontario, there is a need to balance politics and organizational performance requirements.
“Having the ability to locally set targets and performance priorities makes sense” says Michael Schull. Though he cautions that “at the same time, there is a need to measure and report at the health system level what constitutes high quality care.”