Lilford Richard, Mohammed Mohammed A, Spiegelhalter David, Thomson Richard
Department of Public Health and Epidemiology, University of Birmingham, UK.
Lancet. 2004 Apr 3;363(9415):1147-54. doi: 10.1016/S0140-6736(04)15901-1.
The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.
外部机构监测医疗保健结果的历史可以追溯到古代。然而，古今都存在的危险在于，在寻求改进的过程中，死亡率和发病率的比较指标常常被过度解读，从而导致对潜在医疗质量的评判。这样的评判可能会转化为绩效管理策略，表现为任性的制裁（如星级评定）和不合理的奖励（如特殊特权或资金分配）。由此产生的给整个机构贴上污名标签的风险，给医疗保健组织注入了巨大的紧张气氛，并可能将注意力从真正的改进转移到表面的改进甚至是投机行为（即操纵系统）上。这些危险尤其适用于结果和吞吐量的衡量指标。我们认为，外部机构不应使用比较结果数据（排行榜）来评判医院护理质量。尽管在某些高风险手术情况下，它们可能提供合理的质量衡量标准，但在急性医疗环境中却几乎没有效度。利用它们来支持奖惩制度是不公平的，不出所料，往往遭到临床医生和管理人员的抵制。我们进一步认为，尽管结果数据对于研究和监测组织内部的趋势很有用，但那些希望改善患者护理而不是惩罚医生和管理人员的人，应该专注于直接衡量对临床和管理标准的遵守情况。
