How will we ensure standards and accountability?
Tracking and measuring outcome metrics is only part of the mechanism necessary to ensure standards and accountability. In addition to a regular review of outcomes, it is important to establish frequent and regular performance dialogues. Best-practice performance management involves setting out clear, realistic targets and managing performance to those targets. The exhibit below summarises what performance management is and is not.
Commissioners must set up the infrastructure to have regular, robust performance management conversations with provider networks. In addition to integrating performance measures into yearly payments, performance dialogues allow commissioners to identify and help resolve issues before they become a large concern. In addition, they allow commissioners to ensure that statutory obligations are being met.
Provider networks must also set up the infrastructure to have similar conversations with the providers who are members of the network. Exhibit 5.10 is an example of the type of meetings that may be necessary for a provider network to set up. These range from yearly strategic reviews to discussions of performance and effectiveness. It should also include weekly tactical meetings of the management team to discuss urgent issues and take immediate action.
Performance management can involve the potential for gains if aspirational targets are met, and for real losses if a minimum threshold is not reached.
The working group of providers, commissioners and lay partners felt a promising mechanism for commissioners to reward a provider network is to allow the provider network to keep a greater proportion of savings realised when it achieves higher aggregate outcome scores. This incentivises provider networks to increase quality of care while reducing costs.
Rewarding poor performance with financial penalties can be counterproductive. This is because turning around a failing system often requires additional resources. However, shielding provider networks from penalties in the event of poor outcomes can mean that the interests of service users might not be reflected by the incentives. It could also mean that once a provider network is sufficiently far away from reaching the aspirational targets, they no longer have any incentive to perform well. Underperformance should therefore be dealt with by a mixture of peer support, training and financial penalties in the case of substantial underperformance. There should also be a mechanism for penalising management directly, in extreme situations, for underperformance in order to avoid moral hazard while protecting the ability of provider networks to care for service users.
- What systems could you put in place to collect data to track performance of your chosen metrics?
- What governance structures and review meeting timelines will you use to ensure standards and accountability?
To implement the Whole Systems approach you will need to plan for and complete the following:
- Commissioners should review the outcomes selector tool for the groups they want to focus on, and understand the types of outcomes and metrics that could be used.
- Organise discussions between commissioners, providers and lay partners in a locality and decide which outcomes you will track for the given population group.
- Ensure that outcomes and metrics are thought of across all five dimensions, and that you can fill in the framework with the five dimensions with the outcomes you will measure.
- Create a reliable and easy-to-use dashboard to track these outcomes across commissioners and providers.
- Agree on the informatics system that will be put in place to track the outcomes on the dashboard. For more information, see Chapter 11: What informatics functionality will we need?
- Decide how people will be held to account across the various levels of the system for the outcomes that they achieve, including any incentivisation programmes.