What Are the Determinants of Health System Performance?

Findings from the Literature and a Technical Expert Panel

Published in: The Joint Commission Journal on Quality and Patient Safety, Volume 46, Issue 2 (February 2020), Pages 87–98. doi: 10.1016/j.jcjq.2019.11.003

Posted on RAND.org on January 28, 2020

by M. Susan Ridgely, Sangeeta C. Ahluwalia, Ashlyn Tom, Mary E. Vaiana, Aneesa Motala, Marissa Rose Silverman, Alice Y. Kim, Cheryl L. Damberg, Paul G. Shekelle

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The U.S. health care system is the most expensive in the world, but it lags behind many other industrialized nations on multiple measures of effectiveness and quality. This poor performance may have played a role in the push to incentivize health care organizations to achieve high performance over a range of domains. Research is needed to understand the determinants of health system performance.


To identify key attributes of health systems associated with performance, a literature review was conducted. The characteristics identified were compiled into a Web-based rating instrument for use with a Technical Expert Panel composed of leaders in health systems and health services research. A modified Delphi process was initiated using three rounds to develop group consensus.


The expert panel reached consensus on nine broad areas important to health system performance. Panelists also rated which specific attributes within those domains were predictive of performance. Panelists tended to rate the kind of characteristics used in past research (such as size, ownership, and profit status) as only somewhat or not at all important, while rating aspects of culture, leadership, and business execution as very important.


There is limited empirical evidence and understanding of factors associated with health system performance. This study illustrates the value of using a modified Delphi process to bring experiential evidence to the task. These findings may help researchers refine their data collection efforts, policy makers craft better policies to incentivize high performance, and health leaders build better systems.

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