Quality improvement in New Zealand healthcare. Part 5: measurement for monitoring and controlling performance--the quest for external accountability.

In this fifth article in the Series on quality improvement, we examine organisational performance indicators, the consequences of their use, and what policy-makers and clinicians need to do to minimise their potential adverse effects. The Ministry of Health (MOH) and district health boards (DHB) are increasingly using performance indicators to measure activity and are looking at how they can be used to incentivise provider performance. Two different approaches are used: report cards (comparing individuals and organisational performance) and pay-for-performance (which provides financial payments for those organisations or individual providers who do what the funder wants). Given the United Kingdom and the United States experience with both approaches, it would seem prudent for New Zealand to proceed cautiously with using performance indicators to modify clinician behaviour. We argue that the integrity of the system overall is dependent on clinicians taking an interest in the indicators used by the Ministry of Health (MOH) and district health boards (DHBs). Furthermore, those using them must invest in learning about system variation and how this affects the external monitoring of performance.