Measuring health system performance: A new approach to accountability and quality improvement in New Zealand

AbstractIn February 2014, the New Zealand Ministry of Health released a new framework for measuring the performance of the New Zealand health system. The two key aims are to strengthen accountability to taxpayers and to lift the performance of the system's component parts using a ‘whole-of-system’ approach to performance measurement. Development of this new framework – called the Integrated Performance and Incentive Framework (IPIF) – was stimulated by a need for a performance management framework which reflects the health system as a whole, which encourages primary and secondary providers to work towards the same end, and which incorporates the needs and priorities of local communities. Measures within the IPIF will be set at two levels: the system level, where measures are set nationally, and the local district level, where measures which contribute towards the system level indicators will be selected by local health alliances. In the first year, the framework applies only at the system level and only to primary health care services. It will continue to be developed over time and will gradually be extended to cover a wide range of health and disability services. The success of the IPIF in improving health sector performance depends crucially on the willingness of health sector personnel to engage closely with the measurement process

Recent developments in the funding and organisation of the New Zealand health system

During the 1990s, the New Zealand health sector went through a decade of turbulence with a series of major structural changes being introduced in a relatively short period of time. The new millennium brought further change, with the establishment of 21 district health boards and the restoration of a less commercially-oriented system. The sector now appears to be more stable. However many incremental changes are in train and there has been considerable turbulence below the surface as key players jostle for position. This paper reports on some of the recent changes that have occurred in the restructuring of the New Zealand health system. Three issues are discussed: the devolution of funds and decision-making to district health boards, developments in primary health care, and the position of the private health insurance industry

An Evaluation of Health Service Impacts Consequent to Switching from Brand to Generic Venlafaxine in New Zealand under Conditions of Price Neutrality

AbstractObjectiveTo study the health impact on adult New Zealand patients who switch from originator brand to generic venlafaxine.MethodsThe national pharmacy database was used to select patients using venlafaxine for at least 6 months. Switchers and nonswitchers were identified, and switch behavior was compared for a 12-month follow-up period. Change in health service use following switching was also compared between switchers and nonswitchers including use of the emergency department, hospital, and specialist outpatient services over the same period.ResultsApproximately 12% of all originator brand users switched to generic venlafaxine, at least half of whom continued to use the generic throughout the follow-up period to August 1, 2012. Almost 60% of new users of the generic venlafaxine, however, switched to using the originator brand. Aside from a slight reduction in the use of outpatient services among switchers, there were no significant differences in health services use between switchers and nonswitchers for either existing or new venlafaxine users.ConclusionsAlthough both products remain fully subsidized and available, there is little incentive for prescribers, pharmacists, or patients to switch to the less expensive generic brand. If savings to the national New Zealand budget are to be realized, additional policy measures should be implemented to minimize incentives for multiple and reverse switching, and prescribers, as key opinion leaders, could take the lead in promoting generics to their patients

Nursing Turnover and Staffing Practices in New Zealand's DHBs: A National Survey

Nursing turnover is critical issue as nurse shortages throughout the Western world are pulling a strain on health systems. New Zealand's nursing shortage is exacerbated by international recruitment efforts targeting nurses. New Zealand is a participating country in an international study, using an agreed study design and instruments, to determine the real direct and indirect costs of nursing turnover and the systemic costs by also determining the impacts of turnover on patient and nurse outcomes. The paper reports on two components of the study. First, a pilot study was conducted in six countries, including New Zealand, to identify availability of costs and suitability of the instrument. The results of the pilot, that found that many costs were not available, are reported. Second, as part of u national Cost of Nursing Turnover study, Directors of Nursing in the 21 District Health Boards (DHBs) throughout New Zealand were contacted to complete a survey on turnover and workplace practices: 20 participated. In 13 DHBs nursing turnover was a problem, with 5 reporting rates over 20%; 5 DHBs reported low turnover at 5-10%. The survey did not establish how turnover rates were determined. Notwithstanding the importance of attracting and retaining nurses, in every DHB except 5 there are tight controls over recruitment of new staff, and several DHBs reported a freeze on recruiting RNs except for 'specialist' nurse roles

Use of Temporary Nurse Mechanisms by New Zealand's District Health Board

Nursing shortages is a concern globally, and in this context has emerged a research focus on reasons and costs of turnover and retention. A national study on the costs of nursing turnover in New Zealand public hospitals was conducted between 2005-2006, with 12 month’s data collected per randomly selected unit. Annual turnover rates were found to be high at average 39.16%, with a range between 13.83% and 73.17%. Budgeted nurse staffing per unit in is expected to be sufficient to deliver nursing work for the patient population (occupancy, acuity and complexity) and provide for leave (annual, sick, study, family, bereavement etc). In the context of study it was assumed that temporary cover mechanisms were mainly to cover vacancies and occasional unplanned contingencies such as influenza affecting staff, and higher than normal demands for nursing work. The cost of temporary cover would therefore be a cost of turnover. An unexpected finding of the study was that temporary cover mechanisms were widely used, including when actual staff numbers were equal to or exceeded budget, and no consistent relationship within vacancies was evident. It was concluded that management of nursing resource was driven by cost, no strategic, considerations. Published research on use of temporary cover and the effect of such practices on turnover of nurses provided a perspective to critique the funding

Decentralisation of Health Services in Fiji: A Decision Space Analysis

Background: Decentralisation aims to bring services closer to the community and has been advocated in the health sector to improve quality, access and equity, and to empower local agencies, increase innovation and efficiency and bring healthcare and decision-making as close as possible to where people live and work. Fiji has attempted two approaches to decentralisation. The current approach reflects a model of deconcentration of outpatient services from the tertiary level hospital to the peripheral health centres in the Suva subdivision. Methods: Using a modified decision space approach developed by Bossert, this study measures decision space created in five broad categories (finance, service organisation, human resources, access rules, and governance rules) within the decentralised services. Results: Fiji’s centrally managed historical-based allocation of financial resources and management of human resources resulted in no decision space for decentralised agents. Narrow decision space was created in the service organisation category where, with limited decision space created over access rules, Fiji has seen greater usage of its decentralised health centres. There remains limited decision space in governance. Conclusion: The current wave of decentralisation reveals that, whilst the workload has shifted from the tertiary hospital to the peripheral health centres, it has been accompanied by limited transfer of administrative authority, suggesting that Fiji’s deconcentration reflects the transfer of workload only with decision-making in the five functional areas remaining largely centralised. As such, the benefits of decentralisation for users and providers are likely to be limited

Cost-effectiveness of physical activity counselling in general practice

AIM: To assess the cost-effectiveness of the \u27Green Prescription\u27 physical activity counselling programme in general practice. METHOD: Prospective cost-effectiveness study undertaken as part of a cluster randomised controlled trial with 12-month follow-up of 878 \u27less-active\u27 patients aged 40-79 years in 42 general practices in the Waikato. The intervention was verbal advice and a written exercise prescription given by general practitioners, with telephone exercise specialist follow-up compared with usual care. Main outcome measures included cost per total and leisure-time physical activity gain from health-funders\u27 and societal perspectives. RESULTS: Significant increases in physical activity were found in the randomised controlled trial. Programme-cost per patient was NZ170 dollars from a funder\u27s perspective. The monthly cost-effectiveness ratio for total energy expenditure achieved was 11 dollars per kcal/kg/day. The incremental cost of converting one additional \u27sedentary\u27 adult to an \u27active\u27 state over a twelve-month period was NZ1,756 dollars in programme costs. CONCLUSION: Verbal and written physical activity advice given in general practice with telephone follow-up is an inexpensive way of increasing activity for sedentary people, and has the potential to have significant economic impact through reduction in cardiovascular and other morbidity and mortality.<br /

Saturated and trans-fatty acids in UK takeaway food

The aim of the study was to analyze the saturated fatty acid (SFA) and trans-fatty acid (TFA) contents of popular takeaway foods in the UK (including English, pizza, Chinese, Indian and kebab cuisine). Samples of meals were analyzed by an accredited public analyst laboratory for SFA and TFA. The meals were highly variable for SFA and TFA. English and Pizza meals had the highest median amount of SFA with 35.7 g/meal; Kebab meals were high in TFA with up to 5.2 g/meal. When compared to UK dietary reference values, some meals exceeded SFA and TFA recommendations from just one meal. Takeaway food would be an obvious target to reduce SFA and TFA contents and increase the potential of meeting UK recommendations. Strategies such as reformulation and smaller takeaway portion sizes warrant investigation

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

<p>Abstract</p> <p>Background</p> <p>In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?</p> <p>Methods/design</p> <p>The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.</p> <p>Discussion</p> <p>At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.</p