No consensus on what defines a ‘high-performing’ health system

If you’re looking for a strict definition of what makes for a “high-performing” health system, you’re out of luck, according to a new study published in The Joint Commission Journal on Quality and Patient Safety.

Funded by the Agency for Healthcare Research and Quality (AHRQ), the study searched through articles and other studies published through PubMed and WorldCat databases between 2005 and 2015 which measured hospital or health system performance. Researchers also examined the Grey Literature Report published by the New York Academy of Medicine from its inception in 1999 through January 2016. What they were looking for was some combination of “high-performing” and a type of healthcare organization, including “provider,” “health plan,” “hospital” or “system.”

It found a total of 377 references, but no consistent definition of what makes for a high-performing health system.

“The literature does not support a shared understanding or common use of a definition of high performance with respect to a healthcare delivery system or the components of a delivery system, including hospitals, clinics, or nursing homes,” wrote lead author Sangeeta Ahluwalia, PhD, policy researcher at the RAND Corporation, and her coauthors. “Absent a consistent definition with agreed-on metrics, we are significantly limited in our ability to compare healthcare delivery systems by performance and to develop and implement meaningful policies to achieve high performance.”

In the absence of a consistent definition, the study found articles “variably defined high performance” across several different dimensions:

• Quality (93 percent of articles)
• Cost (67 percent)
• Access (35 percent)
• Equity (26 percent)
• Patient experience (21 percent)
• Patient safety (18 percent)

Three of four articles used one or more of these dimensions, the most common pairing being quality and cost. However, only five articles used five or more dimensions and almost a third offered only a concept of high performance but didn’t include any specific metrics.

This lack of consensus was found to be problematic by the authors for several reasons. Some of these dimensions have overlap, like whether readmission rates are a measure of quality or a measure of resources (and thus cost). While examining quality and cost data may be informative, they wrote, those measures alone shouldn’t be the sole defining characteristics of high performance.

What Ahluwalia and her coauthors recommended was a six-dimension definition of high performance based on the categories which they found to be most often used to illustrate high performance.

“The critical need for a definition of high performance that comprehensively and accurately reflects our expectations for healthcare is made apparent by policy makers and payers' growing focus on high performance,” they wrote. “It is important to develop a shared common understanding of high performance and identify and agree on common metrics that in aggregate could be used to identify healthcare delivery systems that are high-performing in the broader sense.”