Efficiency, effectiveness, equity (E3). Evaluating hospital performance in three dimensions.

There are well-established frameworks for comparing the performance of health systems cross-nationally on multiple dimensions. A sub-set of such comprehensive schema is taken up by criteria specifically applied to health service delivery, including hospital performance. We focus on evaluating hospital performance, using the New Zealand public hospital sector over the period 2001-2009 as a pragmatic and illustrative case study for cross-national application. We apply a broad three-dimensional matrix--efficiency, effectiveness, equity--each based on two measures, and we undertake ranking comparisons of 35 hospitals. On the efficiency dimension--relative stay, day surgery--we find coefficients of variation of 10.8% and 8.5% respectively in the pooled data, and a slight trend towards a narrowing of inter-hospital variation over time. The correlation between these indicators is low (.20). For effectiveness--post-admission mortality, unplanned readmission--the coefficient of variation is generally higher (24.1% and 12.2%), and the trend is flat. The correlation is again low (.21). The equity dimension is assessed by quantifying the degree of ethnic and socio-economic variation for each hospital. The coefficient of variation is much higher--40.7-66.5% for ethnicity, 55.8-84.4% for socio-economic position--the trend over time is mixed, and the correlation is moderate (.41). On averaging the rank of hospitals across all measures it is evident that there is limited consistency across the three constituent dimensions. While it is possible to assess hospital performance across three dimensions using an illustrative set of standard measures derived from routine data, there appears to be little consistency in hospital rankings on these New Zealand data for the period 2001-2009. However, the methodology of using rankings derived from readily available data--possibly allied with multiple or composite indicator models--has potential for the cross-national comparison of hospital profiles, and assessments in three dimensions provide a more holistic and rounded account of performance.