Developing and Implementing a Framework for System Level Measures: lessons from New Zealand

Abstract

Background: Measuring performance is now the norm in health systems. System Level Measures (SLMs), implemented at New Zealand’s Counties Manukau Health (CMH) are designed to support quality improvement activities undertaken across the health system using only a small set of measures. While the healthcare and performance measurement literature contains information regarding the facilitators and barriers to quality improvement initiatives, there is an absence of studies into whether these factors are germane to the establishment and implementation of a SLM framework. Methods: A purposive sample of thirteen senior managers and clinicians involved in the construction and implementation of SLMs were invited to participate. Semi-structured telephone interviews were completed and recordings transcribed verbatim. Transcriptions were thematically analysed using a general inductive approach. Findings: In total, ten interviews took place. Six facilitative themes were identified including: dispersed and focused leadership; communication; data; alignment of the measures with organisational strategic data; alignment of the measures with organisational strategic plans and values; stakeholder engagement; and a dedicated project team. Conversely, five themes were identified that hindered the process. These were: reaching consensus; perfection versus pragmatism; duplication and process burden; achieving buy-in and workload. Discussion: The factors that facilitate and hinder establishing and implementing a framework of SLMs are common to other quality improvement approaches. However, this study demonstrated that these factors were also germane to SLMs. These findings are of particular relevance as researchers and policy makers elsewhere increasingly aim to adopt measurement arrangements for health systems that address equity, safety, quality, access and cost. Abbreviations: CMH – Counties Manukau Health; DHB – District Health Board; IHI – Institute for Healthcare Improvement; QI – Quality Improvement; SLM – System Level Measure.