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Table 1 Measurable, functional and goal-oriented constructs

From: Combining patient, clinical and system perspectives in assessing performance in healthcare: an integrated measurement framework

ConstructsKey question / themeExample of indicators
1. Measurable constructs
 Patients’ needs and expectations
What is needed? In what format is it needed?
Patients’ need for healthcare can be quantified in measures of ill health, prevalence of chronic illness, limitations to daily activities caused by health issues, or health literacy. Expectations can relate to personal interactions (courtesy, engagement), facilities (e.g. buildings, equipment, staff), processes (e.g. waiting lists, accessing care), and health outcomes (e.g. the anticipated effects on patients’ health).Patients’ needs: Number of people in poor health; Self-reported health status; Prevalence of diabetes; Health literacy.
Patients’ expectations: Importance of politeness and courtesy; Perception of delays or waiting times; Desire for choice and engagement in care decisions.
 Healthcare resources and structures
What is invested in healthcare? How is it configured?
The investments in, allocation and organisation of healthcare resources. It includes the tangible inputs to the healthcare system and the way they are ordered and managed such as financial and human resources, equipment, buildings and organisational hierarchies. More intangible aspects include culture and the symbolic structures established, such as values and organisational norms.Healthcare resources: Number of doctors, nurses; Financial and human resources invested.
Healthcare structures; Organisational models of care; Organisational climate and culture; Allocation models.
 Healthcare services
What type and how many services are delivered? In what manner are they delivered?
Counts and attributes of the goods and services provided to patients. The core activity of healthcare providers, this construct includes consultations, surgeries, pharmaceuticals, diagnostic tests, and treatments (the amount of care provided). In addition, it includes the characteristics of the service provided (the way care is provided).Healthcare services: Number of surgeries; Number of emergency department visits; Receipt of care; Healthcare quality: politeness; respect; precision; consistency.
 Healthcare processes, functions and context
How is healthcare organised? How is it functioning?
A focus on standard operating practices and how various components of the system interact together during the process of delivering services. This includes many sub-constructs related to the flow of services and information, and interactions between professionals and other providers, and between providers and the broader context they operate within.Healthcare processes: Models of care; Patient pathways and protocols; Coordination and integration processes; Flow of information; Collaboration.
 Healthcare outcomes
Have needs been fulfilled? Have expectations been met?
A focus on health and wellbeing. Metrics are often based on patient reported measures and activities of daily living. Includes physical, psychological, social effects of care and maybe also the outcomes that are generated by experience of care such as trust and confidence in capacity to manage care.Number of deaths per 100,000 population
Number of healthcare associated infections
Health-related quality of life measures
2. Functional and relational constructs of performance – Patient perspective – accessibility, quality and outcomes
 Accessibility
Is healthcare provided when, by whom and where needed? Is healthcare provided at the expected cost and time?
The extent to which patients are able: to recognise and identify their healthcare needs; to seek care; to reach providers of care; to pay for care; and to receive care that is proportionate and matched to their needs. Metrics quantify whether services can be easily sought, reached, obtained and adhered to. Includes sub-constructs: affordability; availability of services; timeliness; unmet needs; organisational accommodation; social and cultural acceptability.Out of pocket costs
Number of visits relative to number of expected visits
Patient survey data measuring reported barriers to care
Waiting times / timeliness / punctuality
 Appropriateness
Is the right healthcare provided, in the right way, and in the right amount?
The extent to which patients receive services that respond to: a) their health needs,
b) align with best-practice models of care; c) is delivered in a technically proficient way; d) in accordance with their expectations about the manner in which they should be treated
Compliance with recommended care (e.g. proportion of AMI patients discharged on preventive medications)
Patient survey data on patient-centredness
 Safety
Is care provided in a way that prevents harm and does not cause harm to patient?
Incorporates the notion of risk – are processes in place to prevent unnecessary harm to patients –both minimising iatrogenic harm and acting in a way that interrupts patient deterioration and circumvents exacerbations that are amenable to care.Hand hygiene or surgical checklists compliance
Infection control
Adverse events
 Effectiveness
Does healthcare make a positive difference to patients’ health? Are needs of patients reduced? Is disease progression altered?
The extent to which healthcare services deliver to patients the benefits expected. Measurement assesses whether services reduced the incidence, duration, intensity or consequences of patients’ presenting health problem. Metrics include risk standardised mortality and readmission rates, as well as patient confidence in providers and the broader system.Patient reported outcome measures
Relative survival
Symptom control
Changes in activities of daily living
3. Functional and relational constructs of performance – static system perspective
 Coverage
Are healthcare resources and structures established according to needs and expectations?
The extent to which services rendered meet the potential need for those services in a community.Schedule of available funded procedures and treatments
Patient reported confidence in ability to access care
Consequences of unmet need (e.g. dental caries)
 Productivity
Does the healthcare system produce sufficient quantity and quality of care for the resources invested?
The number of goods and services delivered per unit of resource. Often referred to as technical efficiency.Consultations per physician
Scans per CT facility
Cost per bed day
 Efficiency
Does the system achieve good outcomes and patients’ experiences for the resources invested?
The extent to which healthcare systems and organisations make the best use of available resources. Assessed by quantifying the amount of valued outcomes achieved for the resources invested. The definition of valued outcomes is important– more services per unit of input are not necessarily desirable. Metrics focus on value for money; or conversely on waste, duplication and unnecessary care. Relates to allocative and technical efficiency.Unnecessary duplication of tests
Number of consultations per doctor
Relative stay index
4. Functional and relational constructs of performance – dynamic system perspective
 Adaptability
Does the system adapt to changing patients’ needs and expectations across diverse contexts of delivery?
As the demands for healthcare services - and the technologies available to deliver them - change, systems need to be able to adapt to respond, and planning tools need to recognise the interdependencies within the care service and care infrastructure system.Shifts in supply patterns in response to health trends
Uptake rates of effective new technologies
Introduction of new models of care to meet emerging expectations
 Sustainability
Is the quantity and quality of care sustainable in future years? Can the system continue to work at this level of performance?
The extent to which healthcare systems function in ways that meet patients’ current health and healthcare needs without compromising the ability to meet needs in the future. Sustainable systems and organisations adapt to changing circumstances, constraints, opportunities and demands. There are very few direct measures of sustainability and so assessment focuses on quantifying the use of processes proven to improve efficiency, impact and productivityInvestment in Research & Development programs
Utilisation of cost effective alternative models of care
Pace of increase in expenditure
Absenteeism, long term vacancies, use of locums
Assured supply of essential drugs
 Resilience
Can care health outcomes be maintained in the face of unexpected changes and challenges?
At an organisational and system level, resilience is the ability to mount a robust response to unforeseen, unpredicted, and unexpected demands and to resume or continue normal operations. Metrics often focus on disruptions in the continuity of care as indicators of the inability of systems to meet demand. Gap-filling adaptations such as clinician initiatives and improvements to equipment design indicate sources of resilience that are present to help accommodate demands for care.Flexibility – ability to mobilise resources when required
Timeliness in high activity periods in the emergency department
Elective surgery cancellations when there is heightened demand for emergency surgery
5. Goal attainment constructs of performance – population perspective
 Impact
Protecting, promoting and promulgating health
The influence that services have on a population’s overall health and functioning. This construct includes measures of change in public health, or trends in terms of changes in quality of life and wellbeing. Impact measures reflect complexity, the integration of care and the cumulative effect of discrete events, and of health promotion, preventive or curative interventions.Premature mortality
Life expectancy
Activities of daily living
Changes over time in health status
 Equity
Fairness in health, fairness in healthcare
The extent to which everyone in a population has the opportunity to reach their full health potential, equity incorporates the idea that receipt of care, appropriateness of care and outcomes of care should be consistent across social groups and responsive to needs. Equity is not synonymous with equality – but includes the notion of ‘fairness’ – those with greater need should get more care. Horizontal equity refers to the provision of equal healthcare to those who have the same need, regardless of other personal or social characteristics. Vertical equity involves treating population sub-groups differently, according to differential need.Disparities in accessing care for equal need
Infant mortality by Aboriginality