A Framework of System Level Measures Promotes Alliancing and System Integration

Abstract

Introduction: The New Zealand health system is organised by 20 District Health Boards (DHB) and 30 Primary Healthcare Organisations (PHO). In 2012, every DHB was required to enter into a district alliance with the PHOs serving their resident population. The NZ Ministry of Health has co-designed with health sector clinicians, analysts and managers a framework of System Level Measures (SLM) for continuous quality improvement and system integration. Method: Basic underlying principles for SLM were established to determine selection, principally that they were outcomes with a clear focus on health equity. Data had to be available, feasible and timely. Using a collaborative approach engaging Ministry of Health and sector clinicians, data analysts and managers, and consumers a set of six measures has been implemented: ASH rates in 0-4 year old children; Proportion of babies living in a smoke-free home; Patient experience of care; Acute hospital bed days per capita; Amenable mortality; and a Youth Health composite SLM. The SLMs are underpinned by a large set of contributory measures of health processes and activities. A measures library was established as a repository of data definitions and sources in order to standardise measurement nationally and allow comparative analysis. The Ministry of Health has made patient identifiable data held in national collections available down to practice level via secure servers, for local managers and clinicians to use for quality improvement. Each district alliance is required to develop a quality improvement plan based on their analysis of local data on SLM, service configuration and the needs of their local population. The alliance must set an improvement milestone for each SLM and detail the improvement activities it will implement using improvement science methodology. The plan also details the contributory measures that will be used to track local progress and contains signatures of all parties in the alliance. The Ministry of Health releases funding to PHOs for capacity and capability development as seed funding and on approval of the plans. A small incentive funding pool is applied to achievement of SLM milestones. Results: In the first year of implementation, all twenty district alliances submitted a plan by the due date setting improvement milestones for four SLMs. The framework stimulated primary and secondary care clinicians, PHO senior managers and DHB chairs to collaborate on quality improvement. The Ministry gained knowledge about the maturity of alliances and their capability and capacity for improvement science methodology and analytics. This was found highly variable between districts. In the second year, two developmental SLMs were added and the quality of plans improved. Conclusion: New Zealand has developed and implemented a framework of system level health outcome measures to stimulate alliances between primary healthcare and secondary care to engage in quality improvement activities taking a co-design and patient-centred approach. Early indications are promising that the framework can deliver improved outcomes both for the system and the patients.