There is growing interest in the public release of information on the performance of healthcare providers as a means to improve the quality of care and promote transparency and accountability. Countries have made considerable investments in creating systems to make available such information. However, there is lack of systematic comparative assessment of such systems. Thus, there is a need to better understand the drivers behind and leaders of initiatives and their aims and objectives; the nature, frequency and source of information provided; their availability to and usability by the public, and, finally, whether and how these systems might have an impact on the quality of care.
This report aims to contribute to filling these gaps by reviewing information systems reporting on the quality or performance of providers of healthcare (“quality information systems”) in seven countries: Denmark, England, Germany, Italy, the Netherlands, Sweden and the United States. Data collection involved a review of the published and grey literature, complemented by information provided by key informants in the selected countries using a detailed questionnaire.
The review highlights that as the policy context for quality reporting in countries varies, so also does the nature and scope of quality information systems within and between countries. Systems often pursue multiple aims and objectives, which typically are:
- to support patient choice
- to influence provider behaviour to enhance the quality of care
- to strengthen transparency of the provider–commissioner relationship and the healthcare system as a whole
- to hold healthcare providers and commissioners to account for the quality of care they provide and the purchasing decisions they make.
However, system objectives are not always well defined and documented, which makes it difficult to assess whether, and how well, systems achieve their intended aims.
Similarly, quality information systems typically address a number of audiences, including patients (or respectively the general public before receiving services and becoming patients), commissioners, purchasers and regulators. Ultimately, however, the main users of information systems are the providers themselves as the publication of information provides an incentive for improving the quality of care. Most systems have the stated aim to make information on provider performance available to patients thus supporting choice of provider. Yet there are examples of systems that, in their present format, seem to be ill-suited to meet patients’ information needs as the nature of information collected and their presentation might require specialist knowledge in order to be usable and useful. This reflects, to a certain extent, the origins of several of the information systems reviewed here, which have developed gradually, often through a combination of some form of “bottom up” initiatives and “top down” regulation. In Sweden, for example, the national quality registries were initially developed by clinicians and professional networks, while requirements for quality reporting for hospitals in Germany were defined by the legislator. The Weisse Liste in Germany is developed by a private foundation in collaboration with associations of patient and consumer organisations.
As quality information systems vary in their objectives and target audiences, so does the nature and scope of data provided. In most countries, several systems co-exist, frequently, although not always, serving slightly different purposes. The scope ranges from those whose sole purpose it is to inform about one aspect of performance, typically waiting times (e.g. Ventetider in Denmark and Väntetider i Vården in Sweden), to systems that give users access to detailed information about the quality of care delivered by individual providers. Where detailed information on provider performance is available, it tends to focus on hospitals with only a minority of systems also providing information on the quality of primary and/or preventive care (e.g. NHS Choices in England, Zichtbare Zorg in the Netherlands, and Öppna jämförelser in Sweden). Furthermore, only a few systems provide patient ratings based on systematic surveys, including patients’ experience (e.g. NHS Choices, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in the United States, and KiesBeter in the Netherlands), patient satisfaction (Qualitätskliniken in Germany) or provide an opportunity for direct feedback from patients (e.g. the ongoing pilot project by AOK-Gesundheitsnavigator in Germany).
Governments and health authorities play a key role in operating and funding quality information systems. Where healthcare governance has been devolved to regions or countries, quality reporting typically also involves regional governments. Furthermore, professional groups are involved, for example by operating the databases on clinical quality in Denmark or the national quality registries in Sweden. Dr Foster Intelligence in England has originated in the private for profit sector and is operated as a public-private partnership.
Although countries reviewed here have developed a variety of quality information systems for a range of different audiences, the evidence about the impact of these systems is fairly limited. Systematic evaluative work is mainly available for the United States, suggesting that public reporting can improve the quality of care in some areas. However, the effects of information systems on quality of care are difficult to isolate as these frequently are part of broader quality initiatives. Also, the requirements for increased reporting necessitate improved documentation, which may explain some of the (initially) observed effects of quality reporting on improvements.