“If you can't measure it, you can't manage it.” - Peter Drucker
If we are serious about making integrated care a reality, we need to measure how we are doing, and ensure we are continuing to improve the performance of our integrated care systems (ICSs) and constituent places. The outcomes of success for any integrated health and care system will be complex and the measures that matter will vary from a national, local or person-centred context.
Logic and emotion – the two paradigms of healthcare
The traditional view would use the focus of the quadruple aim to describe good quality improvement metrics: health and wellbeing of the population, outcomes and experience of care, cost efficiency for the delivery of care, and the experience of those delivering services.
It is only when we incorporate these two cornerstones of healthcare that we will truly understand our progress
It is important, however, that we widen the lens to include measurements that reflect the human experience of care – both logical measures and those that describe the emotional impact of the overall system.* It is only when we can incorporate these two cornerstones of healthcare that we will truly understand our progress. We will also make health inequalities more visible.
Improving the health and wellbeing of the population and the experience of the workforce are as much to do with how the system feels as how it performs. This framework would not only support individual quality improvement within ICSs but, if standardised, would allow for benchmarking comparison between normalised populations. The metrics could be divided into four domains:
- inputs of care
- processes of care
- outputs of care
- overall outcomes.
Start at the end – with outcomes
It helps to start with the outcomes you want to see, then establish the inputs and processes you need in place, and the outputs you would require to deliver these outcomes.
Logical outcomes metrics include:
- system-level community health and wellbeing, for example reductions in avoidable deaths for treatable conditions, improved mental health and wellbeing and the proportion of populations engaged in healthy lifestyle behaviour.
Emotional outcomes include:
- realising the personal health outcomes of people and communities relating to measures of improved quality of life, confidence in managing one’s own health, remaining independent and better managing existing health conditions
- user and carer experiences, such as shared decision-making, care planning, communication and information sharing, and care coordination. Confidence in and being able to navigate the system.
Measuring system inputs and processes – ‘the ingredients and the recipes’
Once whole ICS outcome measures are agreed, the focus can shift to the measurement of getting there, starting with the inputs of care or what assets we have – the people, estates, equipment and IT, and the processes of what we do.
Measuring inputs at system level is an important indicator of allocative efficiency, ensuring investment is matched against health benefits across an ICS. It also exposes situations of robbing Peter to pay Paul in an attempt to shore up organisational resilience. This is particularly true in strategic workforce planning at ICS level. It is therefore important to establish staffing levels, recruitment and retention levels and metrics that can capture staff wellbeing across the whole system.
Measuring system resource allocation for estate management and enabling digital technology are also important. But it would be a mistake to believe that ICS-level measures of these inputs to care is an aggregation of those that exist at organisational level. They need to be measured and managed collectively.
Measuring the processes of an ICS is not limited to clinical care metrics, such as unexplained variation in care or concordance with current evidence . It includes non-clinical processes such as supply chain optimisation, procurement efficiency, patient flow and ease of navigation.
We should be routinely measuring population confidence and trust in the system, how joined up and navigable it feels and if people feel treated with respect and compassion in the planning and delivery of their care
The measurements of the outputs of care, dear to traditional target culture, continue to be an important part of that quality landscape for public accountability, but also highlighting areas in need of improvement, such as access and waiting time metrics.
Intrinsic outputs of an ICS should also include research and contribution of patient data as part of clinical trials to inform better care, if we are to aspire to the achievements that we saw during the pandemic.
Important as these metrics are, they should be supplemented with the more human aspects of care to include the emotional experience of all people the ICS touches, those it serves and those working within it. We should be routinely measuring population confidence and trust in the system, how joined up and navigable it feels and if they feel treated with respect and compassion in the planning and delivery of their care. We need to be measuring the satisfaction morale and experience of staff working within the system.
One system to rule them all
It is key that these whole-system ICS metrics need to take sovereignty over traditional organisational metrics. It is only in this way that we can ensure quality improvement priorities, and management focus are on the health of the population rather the health of organisations. We cannot allow a situation where constituent organisations are deemed to be succeeding while the whole system is allowed to fail against its improvement metrics.
Dr Helen Davies is a GP and community integration and PHM clinical lead in Calderdale. Follow her on Twitter @HelenDa21136593