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Performance reporting for consumers: issues for the Australian private hospital sector

Performance reporting for consumers: issues for the Australian private hospital sector A group of consumers of private hospital services and their carers collaborated with staff of a Melbourne private hospital and with industry representatives to develop a consumer-driven performance report on cardiac services. During the development process participating consumers identified situational and structural barriers to their right to be informed of costs, to choice and to quality care. Their growing appreciation of these barriers led them to a different perspective on performance reporting, which resulted in their redirecting the project. The consumer participants no longer wanted a performance report that provided comparative quantitative data. Instead they designed a report that outlined the structures, systems and processes the hospital had in place to address the quality and safety of services provided. In addition, consumer participants developed a decision support tool for consumers to use in navigating the private health care sector. The journey of these consumers in creating a consumer driven performance report for a private hospital service may assist those responsible for governance of Australia's health system in choosing appropriate strategies and mechanisms to enhance private hospital accountability. The situational and institutional industry barriers to choice, information and quality identified by these consumers need to be addressed before public performance reporting for private hospitals is introduced in Australia. tor and consumers must choose among services offered by Background The private health sector contributes significantly to Aus- health insurers, doctors and hospital providers. Ensuring tralia's health care system. In 2003–2004, private hospi- that the consumer is adequately informed of options and tals provided 33.3% of national total beds and 38.6% of costs of treatment is an industry challenge [3]. the 6.84 million patient separations reported nationally [1]. Comprising health insurance, medical practitioners The Australian Government Department of Health and and hospital providers, the private health sector is regu- Ageing (the sponsor) established the Consumer and Pro- lated through a range of legislation that is administered by vider Partnerships in Health (CAPPS) program in early both state and national level organisations. Privately 2000 to increase consumer participation in health care insured consumers seek benefits above public sector serv- [4]. In 2001 two of these CAPPS grants were made availa- ices such as choice of doctor and hospital and timing of ble to private hospitals. This paper describes one of the procedure [2]. There is no coordinating body for the sec- CAPPS private hospital projects; the development of a Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 consumer driven performance report at the Epworth Hos- purposeful reporting approach works with consumers in pital, then a 500 bed not-for-profit private hospital in constructing the report. This partnership guides 'knowl- Melbourne Australia. This project aimed to test a con- edge construction' rather than 'information telling'. sumer driven private hospital performance report. Cognitive science research has shown that the knowledge Hospital performance reporting construction approach provides greater support for the There are three main reasons for public reporting on per- consumer's basic decision making process [29]. Simply, it formance information [5]: supporting consumer choice has been shown that consumers are more likely to find a [6,7], enabling accountability [7,8], and promoting qual- performance report useful when information relevant to ity [8-10]. Supporting consumer choice has been a partic- their needs is made available in the report [30,31]. Given ular focus in the United States, while accountability has the lack of an industry structure to support public report- been the focus in the United Kingdom [11] and Canada ing, the purposeful reporting framework would be prefer- [5]. Accountability has also been the focus of public sector able to a public release method because consumers are reports published by Australian State Governments that actively involved in directing it. In addition this frame- provide comparative data for public hospitals [12]. Use of work is aligned with the private sector's commitment to performance reporting to promote quality is evident in choice and provides principles to guide negotiation. For many countries [5] and public reporting to improve both these reasons, the purposeful reporting method was quality and accountability has become a priority in Aus- expected to deliver more effective performance reporting tralia in the wake of research [13,14] and a number of for consumer decision making. public inquiries [15-20] that highlighted the need for a safer and more accountable health care system [21-24]. Consumer choice requires private health insurers to com- municate the relative benefits of their health insurance Despite the identified need for performance reporting, products [27], and private hospitals and doctors to pro- there has been limited performance information available vide information about treatment costs [3]. Further, com- to consumers of Australian private health care. One of the parative information on hospital and doctor performance limitations has been that Australia does not have a trusted would assist consumer choice of hospital and doctor, at national body to collect, collate and risk-adjust compara- least in non-emergency situations [25]. To explore con- ble hospital and doctor performance data [25] and with- sumer needs for information on products, costs and per- out a trustworthy source, data are unlikely to be used to formance this project engaged a group of consumers and guide decision-making [26]. Only recently has the their carers in the development of a performance report National Government required health insurers to publish for private hospital cardiac services. information about private health insurance products in a way that enables consumers to compare products [27]. Methods From 2007 the Private Health Insurance Ombudsman Setting will publish data to enable consumers to compare prod- Epworth Hospital is a private not-for-profit hospital ucts. located in Melbourne, Australia. At the time of the project the hospital provided cardiac services to approximately In Australia two frameworks for performance reporting 3,600 patients each year through a 58 bed cardiac facility have been described; public release information and pur- supported by a large and well-equipped intensive care poseful reporting to consumers [11]. Public release infor- unit. mation aims to fulfil a provider's duty to disclose pertinent information to the public and by so doing Participants improve the accountability of the health system to citizens Epworth partnered with two consumer groups to source [7]. Hospital performance reports in Australia have typi- participants for this project. Heartbeat Epworth Inc. repre- cally employed a public release framework, focused on sented consumers of acute cardiac surgical services and quality and accountability managed by a central govern- the Cardiomyopathy Association of Australia Ltd. repre- ment body [28]. sented consumers of acute cardiac medical services. Rep- resentatives from these organisations, including In contrast purposeful reporting is tailored to the particu- consumers and their carers, were invited to participate in lar needs of consumer groups and specific decisions such the project from the time of proposal development as choice of hospital or doctor [11]. Purposeful reporting through to completion of the project. aims to promote public accountability by informing con- sumer choice enabling consumers to make informed deci- Process sions, assess quality and contribute to quality A steering committee was established comprising industry enhancement [29]. Unlike the public release method, the stakeholders and consumer representatives and met six Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 times over the life of the 12 month project. The industry mittee and used to develop the performance report format stakeholders represented health insurance, specialist and and content. general medical practitioners and hospital management. Consumer members included the presidents and other Twenty-one participants and carers returned to participate members of the two self help consumer groups. An expe- in focus groups in the final four months of the project. It rienced consumer representative from an independent, was unfortunate that less than half of the consumer par- not-for-profit organisation that promotes consumer per- ticipants were able to continue to attend the focus groups, spectives in the Australian health system through policy but the expected and unexpected health and other issues research and consumer advocacy also participated. An made it difficult for some of the consumers and carers to expert conciliator familiar with the health industry was continue to participate. These focus groups were provided invited to chair so that power differentials of those on the with an opportunity to work with an expert editor of edu- steering committee would be addressed. cation textbooks and a graphic designer to develop the draft report. In these focus groups it was expected that the Four exploratory focus groups were held to explore con- participants would agree on a performance report. In sumer and carer (n = 51) perceptions of cardiac services working towards this goal the participants prioritised 64 provided by Epworth. Two of the focus groups focused on draft measures; relating to access (for example time from cardiac surgical services and two captured the perceptions admission to angiogram); quality of care, (for example of consumers of invasive cardiology services. It was satisfaction with communication from their doctor and important to separate surgery and cardiology as the two satisfaction with nursing skill); and discharge manage- forms of treatment result in different consumer experi- ment (for example consumer confidence going home) ences. Focus group participants were invited by individual [32]. However as the consumer participants explored letter, through a notice in each partner association's news- these measures they began to question the organisational letter and invitations to individual patients following and private health system processes and structures. their rehabilitation program. At this point in time, approximately 10 months into the Of the 51 initial focus group participants the average age 12-month project, the consumers wanted to redirect the was 71 years, 62% were male and 64% had been patients project. They no longer wanted comparative quantitative and the others carers. Participants had been involved in a data on performance; instead they indicated that they range of cardiac related episodes spanning the past two would prefer information on the processes and structures decades. Interventions included; coronary artery bypass employed by the hospital to ensure its standard of care. In grafts, angioplasty and stenting, valve replacement, angi- addition the participants sought information on processes ography and pacemaker implantation. Some members and structures that shaped their access to quality care. The had experienced several admissions and the average project leader responded to this consumer voice and length of stay for the participant group was 7 days. The negotiated with the steering committee and the sponsor demographics of the focus group participants reflected the to change the focus of the project to accommodate the general hospital cardiac patient population. new-found awareness of the consumer participants. A question sheet, developed by the facilitator and project Results and discussion During the project the consumer participants became leader prior to the focus groups, was used to guide discus- sion. During these focus groups participants were intro- increasingly aware of existing structural barriers to reliable duced to the project aims to develop a performance report performance reporting in the Australian private hospital for cardiac services at Epworth Hospital and the structure sector. The consumers discussed factors that limited the and scope of the project. A project team that was answer- amount of information they received on health care costs, able to the steering committee and facilitated by the that reduced their ability to make choices and that project leader obtained a set of potential cardiac service impacted the quality of care. As participants became more performance measures and also examples of performance aware of these barriers they sought ways to address them, reports including a magazine that provided evaluative and changing the direction of the project. This resulted in a comparative information for consumers. These were pro- substantial change to the format of the planned perform- vided to help participants visualise different report for- ance report and to the development of a decision support mats. During the focus groups the participants identified tool to help consumers navigate the private health care and defined consumer quality issues and selected a report industry. format that was meaningful to them. The sessions were taped and analysed by the facilitator. Focus group out- Barriers to information on costs comes were agreed to by consumers in the steering com- Consumers have a recognised right to be informed of the cost implications of a hospital admission [3,33,34]. How- Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 ever the consumer participants of this project voiced con- Barriers to choice cerns about an industry failure to meet this right. Some One of the rationales for performance reporting is that it participants noted that they did not realise until after their facilitates consumer choice [6,7]. However the partici- admission that their health insurance did not cover the pants in this project hotly challenged the idea that they 'throw away tubes and things' used in intensive care [32]. had choice. The participants also became aware that some insurance products excluded particular services. They were con- How many people do have choice? I followed the track, and cerned that insurance companies could sell insurance just ended up here products that excluded emergency cardiac services such as 'stenting'. Indeed one participant won group support You have no choice really. You put your life in your doctor's when he argued that product exclusions for any emer- hands. The alternative is – you are dead. You are not in the gency service was unconscionable, reasoning that, "I can- mood to agree or choose. not get house insurance and not have the house completely insured." In Australia choice of doctor, hospital and timing of pro- cedure is a promoted benefit of private health cover. How- Participants agreed that life saving services needed in a ever the consumers of cardiac services in this project time critical situation should not be excluded from health indicated that situational barriers, such as needing emer- insurance products. The participants reflected that usually gency access to services, often limited their ability to exer- the insurance purchase decision was made quite sepa- cise choice. rately to a decision to access private health care and there was a high risk that the consumer would not link health The consumers also recognised that their ability to exer- insurance purchase with a judgement about their likely cise choice was often limited by structural barriers as well. health service needs. This failure to link relevant informa- Participants acknowledged that referral networks had tion was made worse by the fact that there is typically a impacted their navigation of the private health care sys- considerable period of time between the purchase of pri- tem. One participant described how annoyed he was vate health insurance and its use when accessing health when his general practitioner had sent him to the 'closest' care. This observation led participants to the view that specialist, rather than 'the best' [32]. While they agreed consumers of private health insurance should be that consumers needed to be more 'up front' with their reminded annually of their cover, just as one is for house doctors about their priorities to influence traditional refer- and car insurance. The focus group participants then ring practices, the group conceded that traditional doctor noted that none of them could recall ever receiving such a referral practices and well known communication issues communication from their health insurance provider. may still undermine the consumer choice that is pro- moted in the private health sector. For these reasons con- The participants discussed their experiences trying to sumers felt that it was unrealistic to assume that the obtain information from health care practitioners – indi- provision of a performance report for consumers of car- vidual clinician or team information is not collected and diac services would be sufficient to promote choice with- is certainly not made easily available to consumers. For out structural changes to the private health care system. example the consumers complained that lack of informa- Barriers to consumer interests in quality tion about costs arose because the surgeon may not be able to advise the consumer of the expected anaesthetic The consumer participants reflected on other structural fee. A participant asked, "He [surgeon] selects the anaesthet- barriers that they believed limited the capacity of the ist but says I don't know what it will cost..... How can you cope industry to coordinate relationships between industry with that type of stuff?" stakeholders in the interests of safety and quality of care. Doctors were seen as independent practitioners and their Participants realised that barriers to their right to be cooperation with and contribution to hospital quality informed were structural in nature and highlighted the activities was optional. One participant said; lack of collaboration between the health funds, the doc- tors and the hospitals. This resulted in consumer partici- The problem is doctors are not employed by the hospital. The pants questioning whether a report, which provided hospital hasn't got that much control over the situation. comparative data, would be reliable, or even useful. With this shared awareness, the participants began to seek strat- For this reason, instead of quantitative data on quality and egies to raise consumer awareness of the cost implications safety which the participants felt might not be reliable, the of private health services. participants wanted the report to demonstrate the proc- esses and structures through which the hospital managed the quality of medical care provided. The consumers Page 4 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 wanted particular information on how the hospital medication errors, one of the target areas for risk manage- ensured quality and safety given its limited capacity to ment in Australian health care [35]. The report also pro- impose medical governance. vided information on services with which the patient could engage to enhance their care, such as discharge The capacity of the hospital to deliver on quality was also planning, conciliation process and services linked to questioned due to a perceived structural tension between informed financial consent. Following the project the per- hospitals and health insurance providers. The consumers formance report was distributed to patients admitted to had come to realise that the care they received was not the cardiac units to facilitate their participation in their only based on their clinical need, but was also influenced care. by the arrangements between their health insurance pro- vider and the hospitals and clinicians. These consumer driven changes challenged common understandings of performance reports as a vehicle for The hospital – provider agreements create tension on the providing comparative data on which consumers may hospital between the needs of the patient and needs of the base an informed choice. Indeed the performance report hospital. I was told I could go home and I asked to stay the consumers requested moved beyond an individual longer. They did the calculations and said it was OK. It focus and became a tool to engage the consumer not only becomes uneconomical for hospitals to keep patients. We in their care but also in improving hospital processes. The need to know more, in the interests of transparency. purposeful reporting approach that was employed in this project supported such a move, as the purposeful report- These participant concerns about the structural barriers to ing principles encouraged the involvement of consumers safety and quality of care raised questions of whether a in developing the report, shaping both its content and for- performance report would be useful in promoting mat. Secondly, the purposeful reporting approach sup- accountability. ported strategies to increase consumer involvement in their care and to improve hospital processes [11]. Revised performance report It was anticipated that the cardiac performance report The decision support tool would facilitate consumer choice by providing data on The consumer participants argued that given the situa- access, effectiveness, communication and participation, tional and structural barriers quantitative comparative care, continuity of care, human needs and efficiency [11]. performance reports would not help consumers access, However these dimensions did not meet the information organise and apply information provided by the different needs of the consumers once they had identified the situ- service providers in the private health sector. Instead the ational and structural barriers to information, choice and consumers decided they should develop a decision sup- quality care. When asked to explain the radical shift from port tool to assist other consumers and carers to navigate their earlier position, the consumers explained that as the private health sector from the time of health insurance they became more aware of the data to be presented, it purchase through to health service use. The decision sup- became clear to them that unless it was provided by an port tool was designed to guide consumers through independent trusted source it would not be reliable. They choice of health fund product, doctor, and hospital. For decided that it was naive to believe that comparative data example, the decision tool highlighted health insurance would guide choice in an industry that lacked an inde- product exclusions, referred consumers to each health pendent process for collection, collation, reporting and fund's 'Key Features Guide' to enable comparison of dif- interpretation of data. As one participant said; "data is like ferent products and provided information about ambu- a bikini, what it reveals is interesting but what it conceals is lance service policies. In 2003 the decision tool was vital" [32]. This led to a preference for qualitative data on presented to the existing private health sector peak quality organisational processes. It became apparent that given and safety organisation in the hope of obtaining funding there was no trusted coordinating body these consumers for national distribution, but the tool was not funded. trusted data they could validate from their own experi- Negotiating consumer voice ence. The purposeful reporting framework facilitated consumer The outcome was a seven page performance report that ownership and control and enabled individual consumers outlined the structures and processes by which the hospi- to move beyond their particular interests and act to tal sought to provide quality care, including information improve the situation for others. The steering committee on accreditation, medical governance, the nursing model, provided an opportunity for consumers and carers to col- infection control and medication safety. For example, the laborate with stakeholders to provide the consumers with section on medication safety provided an opportunity for a voice at higher-level decision making. However, redirec- consumers to play a role in reducing the incidence of tion of the project from a cardiac performance report com- Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 prising comparative data may arguably have aligned with Acknowledgements The Australian Government Department of Health and Ageing under its hospital and industry interests, and raises questions about 2000–2001 Consumer Provider Partnerships in Health Project grant whether power distorted negotiations and consumer scheme funded the project. Three consumer organisations participated; voice. The transparency and accountability of the steering Heartbeat Epworth, Cardiomyopathy Association of Australia Ltd and committee process, with the minutes, range of members Health Issues Centre. The authors would also like to acknowledge the and independent expert chair, and the transparent negoti- assistance of Professor Helen Cox of Deakin University who participated ations with the sponsor, played a key role in building con- in the project steering committee and provided advice on drafts. fidence that the decision to redirect the project was indeed consumer driven [4]. Given these checks and balances, it Russ Little, our co-author, died in 2006 and we would like to acknowledge his contribution. In 1984 Russ, a retired communication engineer became was concluded this partnership had facilitated a power an executive member of Heartbeat Epworth and Heartbeat Victoria. He is shift from stakeholders and the project funding body to remembered by the associations as a consumer volunteer of great energy consumers [4]. and was instrumental in the success of this project and this paper. 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Wilson R, Harrison B, Gibberd R, Hamilton J: An Analysis of the sumers need to be addressed before public performance causes of adverse events from the Quality in Australian reporting for private hospitals is introduced in Australia. Health Care Study. Medical Journal of Australia 1999, 170:411-415. This study has highlighted issues in public performance 14. Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J: The Quality in Australian Health Care Study. Medical Journal reporting for private hospital services and suggests the of Australia 1995, 163(6):. need for further research to assist in the development of 15. Bristol Royal Infirmary Inquiry: Learning From Bristol:The Report of the Public Inquiry into children's heart surgery at effective and acceptable accountability strategies and the Bristol Royal Infirmary 1984-1995. London , Published by mechanisms for health markets in liberal democracies. the Bristol Royal Infirmary Inquiry; 2001. 16. 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National Safety and Quality Council; 2005. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Performance reporting for consumers: issues for the Australian private hospital sector

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Springer Journals
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Copyright © 2007 by Sheahan et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-4-5
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17537238
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Abstract

A group of consumers of private hospital services and their carers collaborated with staff of a Melbourne private hospital and with industry representatives to develop a consumer-driven performance report on cardiac services. During the development process participating consumers identified situational and structural barriers to their right to be informed of costs, to choice and to quality care. Their growing appreciation of these barriers led them to a different perspective on performance reporting, which resulted in their redirecting the project. The consumer participants no longer wanted a performance report that provided comparative quantitative data. Instead they designed a report that outlined the structures, systems and processes the hospital had in place to address the quality and safety of services provided. In addition, consumer participants developed a decision support tool for consumers to use in navigating the private health care sector. The journey of these consumers in creating a consumer driven performance report for a private hospital service may assist those responsible for governance of Australia's health system in choosing appropriate strategies and mechanisms to enhance private hospital accountability. The situational and institutional industry barriers to choice, information and quality identified by these consumers need to be addressed before public performance reporting for private hospitals is introduced in Australia. tor and consumers must choose among services offered by Background The private health sector contributes significantly to Aus- health insurers, doctors and hospital providers. Ensuring tralia's health care system. In 2003–2004, private hospi- that the consumer is adequately informed of options and tals provided 33.3% of national total beds and 38.6% of costs of treatment is an industry challenge [3]. the 6.84 million patient separations reported nationally [1]. Comprising health insurance, medical practitioners The Australian Government Department of Health and and hospital providers, the private health sector is regu- Ageing (the sponsor) established the Consumer and Pro- lated through a range of legislation that is administered by vider Partnerships in Health (CAPPS) program in early both state and national level organisations. Privately 2000 to increase consumer participation in health care insured consumers seek benefits above public sector serv- [4]. In 2001 two of these CAPPS grants were made availa- ices such as choice of doctor and hospital and timing of ble to private hospitals. This paper describes one of the procedure [2]. There is no coordinating body for the sec- CAPPS private hospital projects; the development of a Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 consumer driven performance report at the Epworth Hos- purposeful reporting approach works with consumers in pital, then a 500 bed not-for-profit private hospital in constructing the report. This partnership guides 'knowl- Melbourne Australia. This project aimed to test a con- edge construction' rather than 'information telling'. sumer driven private hospital performance report. Cognitive science research has shown that the knowledge Hospital performance reporting construction approach provides greater support for the There are three main reasons for public reporting on per- consumer's basic decision making process [29]. Simply, it formance information [5]: supporting consumer choice has been shown that consumers are more likely to find a [6,7], enabling accountability [7,8], and promoting qual- performance report useful when information relevant to ity [8-10]. Supporting consumer choice has been a partic- their needs is made available in the report [30,31]. Given ular focus in the United States, while accountability has the lack of an industry structure to support public report- been the focus in the United Kingdom [11] and Canada ing, the purposeful reporting framework would be prefer- [5]. Accountability has also been the focus of public sector able to a public release method because consumers are reports published by Australian State Governments that actively involved in directing it. In addition this frame- provide comparative data for public hospitals [12]. Use of work is aligned with the private sector's commitment to performance reporting to promote quality is evident in choice and provides principles to guide negotiation. For many countries [5] and public reporting to improve both these reasons, the purposeful reporting method was quality and accountability has become a priority in Aus- expected to deliver more effective performance reporting tralia in the wake of research [13,14] and a number of for consumer decision making. public inquiries [15-20] that highlighted the need for a safer and more accountable health care system [21-24]. Consumer choice requires private health insurers to com- municate the relative benefits of their health insurance Despite the identified need for performance reporting, products [27], and private hospitals and doctors to pro- there has been limited performance information available vide information about treatment costs [3]. Further, com- to consumers of Australian private health care. One of the parative information on hospital and doctor performance limitations has been that Australia does not have a trusted would assist consumer choice of hospital and doctor, at national body to collect, collate and risk-adjust compara- least in non-emergency situations [25]. To explore con- ble hospital and doctor performance data [25] and with- sumer needs for information on products, costs and per- out a trustworthy source, data are unlikely to be used to formance this project engaged a group of consumers and guide decision-making [26]. Only recently has the their carers in the development of a performance report National Government required health insurers to publish for private hospital cardiac services. information about private health insurance products in a way that enables consumers to compare products [27]. Methods From 2007 the Private Health Insurance Ombudsman Setting will publish data to enable consumers to compare prod- Epworth Hospital is a private not-for-profit hospital ucts. located in Melbourne, Australia. At the time of the project the hospital provided cardiac services to approximately In Australia two frameworks for performance reporting 3,600 patients each year through a 58 bed cardiac facility have been described; public release information and pur- supported by a large and well-equipped intensive care poseful reporting to consumers [11]. Public release infor- unit. mation aims to fulfil a provider's duty to disclose pertinent information to the public and by so doing Participants improve the accountability of the health system to citizens Epworth partnered with two consumer groups to source [7]. Hospital performance reports in Australia have typi- participants for this project. Heartbeat Epworth Inc. repre- cally employed a public release framework, focused on sented consumers of acute cardiac surgical services and quality and accountability managed by a central govern- the Cardiomyopathy Association of Australia Ltd. repre- ment body [28]. sented consumers of acute cardiac medical services. Rep- resentatives from these organisations, including In contrast purposeful reporting is tailored to the particu- consumers and their carers, were invited to participate in lar needs of consumer groups and specific decisions such the project from the time of proposal development as choice of hospital or doctor [11]. Purposeful reporting through to completion of the project. aims to promote public accountability by informing con- sumer choice enabling consumers to make informed deci- Process sions, assess quality and contribute to quality A steering committee was established comprising industry enhancement [29]. Unlike the public release method, the stakeholders and consumer representatives and met six Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 times over the life of the 12 month project. The industry mittee and used to develop the performance report format stakeholders represented health insurance, specialist and and content. general medical practitioners and hospital management. Consumer members included the presidents and other Twenty-one participants and carers returned to participate members of the two self help consumer groups. An expe- in focus groups in the final four months of the project. It rienced consumer representative from an independent, was unfortunate that less than half of the consumer par- not-for-profit organisation that promotes consumer per- ticipants were able to continue to attend the focus groups, spectives in the Australian health system through policy but the expected and unexpected health and other issues research and consumer advocacy also participated. An made it difficult for some of the consumers and carers to expert conciliator familiar with the health industry was continue to participate. These focus groups were provided invited to chair so that power differentials of those on the with an opportunity to work with an expert editor of edu- steering committee would be addressed. cation textbooks and a graphic designer to develop the draft report. In these focus groups it was expected that the Four exploratory focus groups were held to explore con- participants would agree on a performance report. In sumer and carer (n = 51) perceptions of cardiac services working towards this goal the participants prioritised 64 provided by Epworth. Two of the focus groups focused on draft measures; relating to access (for example time from cardiac surgical services and two captured the perceptions admission to angiogram); quality of care, (for example of consumers of invasive cardiology services. It was satisfaction with communication from their doctor and important to separate surgery and cardiology as the two satisfaction with nursing skill); and discharge manage- forms of treatment result in different consumer experi- ment (for example consumer confidence going home) ences. Focus group participants were invited by individual [32]. However as the consumer participants explored letter, through a notice in each partner association's news- these measures they began to question the organisational letter and invitations to individual patients following and private health system processes and structures. their rehabilitation program. At this point in time, approximately 10 months into the Of the 51 initial focus group participants the average age 12-month project, the consumers wanted to redirect the was 71 years, 62% were male and 64% had been patients project. They no longer wanted comparative quantitative and the others carers. Participants had been involved in a data on performance; instead they indicated that they range of cardiac related episodes spanning the past two would prefer information on the processes and structures decades. Interventions included; coronary artery bypass employed by the hospital to ensure its standard of care. In grafts, angioplasty and stenting, valve replacement, angi- addition the participants sought information on processes ography and pacemaker implantation. Some members and structures that shaped their access to quality care. The had experienced several admissions and the average project leader responded to this consumer voice and length of stay for the participant group was 7 days. The negotiated with the steering committee and the sponsor demographics of the focus group participants reflected the to change the focus of the project to accommodate the general hospital cardiac patient population. new-found awareness of the consumer participants. A question sheet, developed by the facilitator and project Results and discussion During the project the consumer participants became leader prior to the focus groups, was used to guide discus- sion. During these focus groups participants were intro- increasingly aware of existing structural barriers to reliable duced to the project aims to develop a performance report performance reporting in the Australian private hospital for cardiac services at Epworth Hospital and the structure sector. The consumers discussed factors that limited the and scope of the project. A project team that was answer- amount of information they received on health care costs, able to the steering committee and facilitated by the that reduced their ability to make choices and that project leader obtained a set of potential cardiac service impacted the quality of care. As participants became more performance measures and also examples of performance aware of these barriers they sought ways to address them, reports including a magazine that provided evaluative and changing the direction of the project. This resulted in a comparative information for consumers. These were pro- substantial change to the format of the planned perform- vided to help participants visualise different report for- ance report and to the development of a decision support mats. During the focus groups the participants identified tool to help consumers navigate the private health care and defined consumer quality issues and selected a report industry. format that was meaningful to them. The sessions were taped and analysed by the facilitator. Focus group out- Barriers to information on costs comes were agreed to by consumers in the steering com- Consumers have a recognised right to be informed of the cost implications of a hospital admission [3,33,34]. How- Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 ever the consumer participants of this project voiced con- Barriers to choice cerns about an industry failure to meet this right. Some One of the rationales for performance reporting is that it participants noted that they did not realise until after their facilitates consumer choice [6,7]. However the partici- admission that their health insurance did not cover the pants in this project hotly challenged the idea that they 'throw away tubes and things' used in intensive care [32]. had choice. The participants also became aware that some insurance products excluded particular services. They were con- How many people do have choice? I followed the track, and cerned that insurance companies could sell insurance just ended up here products that excluded emergency cardiac services such as 'stenting'. Indeed one participant won group support You have no choice really. You put your life in your doctor's when he argued that product exclusions for any emer- hands. The alternative is – you are dead. You are not in the gency service was unconscionable, reasoning that, "I can- mood to agree or choose. not get house insurance and not have the house completely insured." In Australia choice of doctor, hospital and timing of pro- cedure is a promoted benefit of private health cover. How- Participants agreed that life saving services needed in a ever the consumers of cardiac services in this project time critical situation should not be excluded from health indicated that situational barriers, such as needing emer- insurance products. The participants reflected that usually gency access to services, often limited their ability to exer- the insurance purchase decision was made quite sepa- cise choice. rately to a decision to access private health care and there was a high risk that the consumer would not link health The consumers also recognised that their ability to exer- insurance purchase with a judgement about their likely cise choice was often limited by structural barriers as well. health service needs. This failure to link relevant informa- Participants acknowledged that referral networks had tion was made worse by the fact that there is typically a impacted their navigation of the private health care sys- considerable period of time between the purchase of pri- tem. One participant described how annoyed he was vate health insurance and its use when accessing health when his general practitioner had sent him to the 'closest' care. This observation led participants to the view that specialist, rather than 'the best' [32]. While they agreed consumers of private health insurance should be that consumers needed to be more 'up front' with their reminded annually of their cover, just as one is for house doctors about their priorities to influence traditional refer- and car insurance. The focus group participants then ring practices, the group conceded that traditional doctor noted that none of them could recall ever receiving such a referral practices and well known communication issues communication from their health insurance provider. may still undermine the consumer choice that is pro- moted in the private health sector. For these reasons con- The participants discussed their experiences trying to sumers felt that it was unrealistic to assume that the obtain information from health care practitioners – indi- provision of a performance report for consumers of car- vidual clinician or team information is not collected and diac services would be sufficient to promote choice with- is certainly not made easily available to consumers. For out structural changes to the private health care system. example the consumers complained that lack of informa- Barriers to consumer interests in quality tion about costs arose because the surgeon may not be able to advise the consumer of the expected anaesthetic The consumer participants reflected on other structural fee. A participant asked, "He [surgeon] selects the anaesthet- barriers that they believed limited the capacity of the ist but says I don't know what it will cost..... How can you cope industry to coordinate relationships between industry with that type of stuff?" stakeholders in the interests of safety and quality of care. Doctors were seen as independent practitioners and their Participants realised that barriers to their right to be cooperation with and contribution to hospital quality informed were structural in nature and highlighted the activities was optional. One participant said; lack of collaboration between the health funds, the doc- tors and the hospitals. This resulted in consumer partici- The problem is doctors are not employed by the hospital. The pants questioning whether a report, which provided hospital hasn't got that much control over the situation. comparative data, would be reliable, or even useful. With this shared awareness, the participants began to seek strat- For this reason, instead of quantitative data on quality and egies to raise consumer awareness of the cost implications safety which the participants felt might not be reliable, the of private health services. participants wanted the report to demonstrate the proc- esses and structures through which the hospital managed the quality of medical care provided. The consumers Page 4 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 wanted particular information on how the hospital medication errors, one of the target areas for risk manage- ensured quality and safety given its limited capacity to ment in Australian health care [35]. The report also pro- impose medical governance. vided information on services with which the patient could engage to enhance their care, such as discharge The capacity of the hospital to deliver on quality was also planning, conciliation process and services linked to questioned due to a perceived structural tension between informed financial consent. Following the project the per- hospitals and health insurance providers. The consumers formance report was distributed to patients admitted to had come to realise that the care they received was not the cardiac units to facilitate their participation in their only based on their clinical need, but was also influenced care. by the arrangements between their health insurance pro- vider and the hospitals and clinicians. These consumer driven changes challenged common understandings of performance reports as a vehicle for The hospital – provider agreements create tension on the providing comparative data on which consumers may hospital between the needs of the patient and needs of the base an informed choice. Indeed the performance report hospital. I was told I could go home and I asked to stay the consumers requested moved beyond an individual longer. They did the calculations and said it was OK. It focus and became a tool to engage the consumer not only becomes uneconomical for hospitals to keep patients. We in their care but also in improving hospital processes. The need to know more, in the interests of transparency. purposeful reporting approach that was employed in this project supported such a move, as the purposeful report- These participant concerns about the structural barriers to ing principles encouraged the involvement of consumers safety and quality of care raised questions of whether a in developing the report, shaping both its content and for- performance report would be useful in promoting mat. Secondly, the purposeful reporting approach sup- accountability. ported strategies to increase consumer involvement in their care and to improve hospital processes [11]. Revised performance report It was anticipated that the cardiac performance report The decision support tool would facilitate consumer choice by providing data on The consumer participants argued that given the situa- access, effectiveness, communication and participation, tional and structural barriers quantitative comparative care, continuity of care, human needs and efficiency [11]. performance reports would not help consumers access, However these dimensions did not meet the information organise and apply information provided by the different needs of the consumers once they had identified the situ- service providers in the private health sector. Instead the ational and structural barriers to information, choice and consumers decided they should develop a decision sup- quality care. When asked to explain the radical shift from port tool to assist other consumers and carers to navigate their earlier position, the consumers explained that as the private health sector from the time of health insurance they became more aware of the data to be presented, it purchase through to health service use. The decision sup- became clear to them that unless it was provided by an port tool was designed to guide consumers through independent trusted source it would not be reliable. They choice of health fund product, doctor, and hospital. For decided that it was naive to believe that comparative data example, the decision tool highlighted health insurance would guide choice in an industry that lacked an inde- product exclusions, referred consumers to each health pendent process for collection, collation, reporting and fund's 'Key Features Guide' to enable comparison of dif- interpretation of data. As one participant said; "data is like ferent products and provided information about ambu- a bikini, what it reveals is interesting but what it conceals is lance service policies. In 2003 the decision tool was vital" [32]. This led to a preference for qualitative data on presented to the existing private health sector peak quality organisational processes. It became apparent that given and safety organisation in the hope of obtaining funding there was no trusted coordinating body these consumers for national distribution, but the tool was not funded. trusted data they could validate from their own experi- Negotiating consumer voice ence. The purposeful reporting framework facilitated consumer The outcome was a seven page performance report that ownership and control and enabled individual consumers outlined the structures and processes by which the hospi- to move beyond their particular interests and act to tal sought to provide quality care, including information improve the situation for others. The steering committee on accreditation, medical governance, the nursing model, provided an opportunity for consumers and carers to col- infection control and medication safety. For example, the laborate with stakeholders to provide the consumers with section on medication safety provided an opportunity for a voice at higher-level decision making. However, redirec- consumers to play a role in reducing the incidence of tion of the project from a cardiac performance report com- Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:5 http://www.anzhealthpolicy.com/content/4/1/5 prising comparative data may arguably have aligned with Acknowledgements The Australian Government Department of Health and Ageing under its hospital and industry interests, and raises questions about 2000–2001 Consumer Provider Partnerships in Health Project grant whether power distorted negotiations and consumer scheme funded the project. Three consumer organisations participated; voice. The transparency and accountability of the steering Heartbeat Epworth, Cardiomyopathy Association of Australia Ltd and committee process, with the minutes, range of members Health Issues Centre. The authors would also like to acknowledge the and independent expert chair, and the transparent negoti- assistance of Professor Helen Cox of Deakin University who participated ations with the sponsor, played a key role in building con- in the project steering committee and provided advice on drafts. fidence that the decision to redirect the project was indeed consumer driven [4]. Given these checks and balances, it Russ Little, our co-author, died in 2006 and we would like to acknowledge his contribution. In 1984 Russ, a retired communication engineer became was concluded this partnership had facilitated a power an executive member of Heartbeat Epworth and Heartbeat Victoria. He is shift from stakeholders and the project funding body to remembered by the associations as a consumer volunteer of great energy consumers [4]. and was instrumental in the success of this project and this paper. 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National Safety and Quality Council; 2005. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes)

Journal

Australia and New Zealand Health Policy – Springer Journals

Published: May 30, 2007

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