Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma
Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma
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DOI：
10.1016/s0140-6736(04)15901-1
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发表时间：
2004-04-03
期刊：
影响因子：
168.9
通讯作者：
Thomson, R
中科院分区：
文献类型：
--
作者：
Lilford, R;Mohammed, MA;Thomson, R
外部机构监测医疗保健结果的历史可以追溯到古代。然而，现在和当时一样，危险在于在寻求改进的过程中，死亡率和发病率的比较指标常常被过度解释，导致对基本护理质量的判断。这种判断可以转化为绩效管理策略，表现为反复无常的制裁（例如星级评定）和不合理的奖励（例如特殊自由或财务分配）。由此产生的对整个机构进行污名化的风险会给医疗保健组织带来巨大的压力，并可能将注意力从真正的改进转移到表面的改进，甚至是游戏行为（即操纵系统）。这些危险尤其适用于结果和吞吐量的衡量。我们认为，外部机构不应使用比较结果数据（排行榜）来判断医院护理的质量。尽管它们可能在某些高风险手术情况下提供合理的质量衡量标准，但在紧急医疗环境中几乎没有有效性。使用它们来支持奖励和惩罚制度是不公平的，并且毫不奇怪地经常受到临床医生和管理人员的抵制。我们进一步认为，尽管结果数据对于组织内的研究和监测趋势有用，但那些希望改善患者护理而不惩罚医生和管理人员的人应该集中精力直接衡量对临床和管理标准的遵守情况。
The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.