Government plans for public reporting of performance data in health care: the case for

For vast amounts of performance data are collected in the Australian health system, many of which are released by agencies such as the Australian Institute of Health and Welfare, state and territory health departments and the Australian Bureau of Statistics. However, merely releasing performance data is different from publicly reporting such data. Public reporting incorporates interpretation and comparisons that make the data meaningful for the community.

Public reporting of health care performance has three major uses: (i) to ensure accountability — the Australian public, which pays for health care, is entitled to assess the effectiveness and efficiency of health care and to press for change as needed; (ii) to stimulate action by health care providers that leads to improvements; and (iii) to give consumers information on which they can base their expectations of health services and individual health care choices.

All of these uses are important, and the scrutiny afforded by public reporting of performance should therefore be welcomed. It is difficult to determine what types of reporting represent the best investment, because the consequences of public reporting are difficult to measure. The quantum of research on the effects of any complex health policy intervention is scant. Unsurprisingly then, evidence on the value of public reporting is currently limited.1,2

What have we learnt from the international experience? Research in the United Kingdom and the United States shows a thirst among consumers for publicly reported performance data, while pointing out the difficulty of producing data that people can readily use for making health care choices.2 In neither the UK nor the US has patient choice in itself been shown to have had a reliable influence on health care quality. However, when the public is made aware of poor health care service performance, calls for political action are common. This is a desirable outcome.

Public reporting — particularly reporting of institutional performance — consistently stimulates health care providers to improve quality.1 For example, after the first publication of comparative cardiac surgery outcomes in New York State, some surgeons who recognised that they were outliers on performance scales voluntarily changed their scope of practice, or retired. More commonly, it is institutions that undergo performance evaluations, and they usually respond vigorously to improve care processes and patient outcomes. This is especially so when public reporting is framed by expectations that people understand and value, such as accompanying goals and targets.2

Does performance measurement corrupt the delivery of health care? It is secrecy that corrupts. The absence of public reporting generates suspicion and cynicism among both clinicians and the public. Notably, the Australian Medical Association submission on the National Health Reform Amendment (National Health Performance Authority) Bill 2011 advocated stronger investigative and disciplinary powers for the National Health Performance Authority and, importantly, a mandatory requirement to release reports.

Opponents of public reporting highlight the potential for merely improving the data rather than the quality of care (for instance by finding more risk factors to include or reclassifying chairs as beds) and for neglect of high-risk patients, but evidence from the UK suggests that both are rare. The introduction of targets and public reporting of emergency department waiting-time data drove real reform.3 In a study of more than 27 000 patients who had cardiac surgery, risk-adjusted mortality fell after the introduction of public reporting, and there was no evidence that fewer high-risk patients were offered surgery.4

Some Australian clinical leaders choose to focus their opposition to public reporting on the impossibility of providing adequate risk adjustment — that is, of fully accounting for the differences between individuals and their circumstances. This is an argument that, when taken to extremes, would invalidate most of the evidence base for medical practice. However, reporting of process indicators can reduce the need for, and the debate over, sufficient risk adjustment.

Rather than corrupting delivery, the Queensland experience — where there is timely return of data to health care providers, and performance measures are accompanied by reporting on the institutional responses to the data — has shown that public performance reporting can create a culture of improvement.5

Could the personal cost to the clinicians and managers be too great to justify implementation of public reporting? Public reporting affords protections and benefits, and should be welcomed as the price of public service and funding. The risk of unfair reproach will be mitigated by the use of reliable performance measures, timeliness, high-quality data, rigorous analysis, and integrity and sensitivity in reporting results.

Review, comparison and criticism are essential components of professional practice. The National Open Disclosure Standard requires clinicians to share uncomfortable truths about adverse events with individual patients. Honesty is a central value of professionalism, and the wellbeing of patients must take precedence over professional self-interest. Public performance reporting promotes strong adherence to these values and therefore should be at the core of good health system governance.