The Performance Assessment Tool for quality improvement in
Hospitals
PATH’09 – Call for participation
Equity, solidarity and participation are core values of the WHO Member States as stated in the
Tallinnn Charter on Health Systems, Health and Wealth, and accountability and transparency
are essential to achieve those.1 Health systems in the European Region are under growing
pressure to optimize their performance so as to meet the health needs of the population.
Functions carried out by the hospitals are an integral part of and contribute to the performance
of health systems.
Hospitals are currently facing many challenges. Pressures for cost containment are increasing
and a sound resource allocation is necessary to continue achieving the hospital’s mission. By
signing the Tallinnn Charter, Member States explicitly recognized that “patients want access to
quality care and to be assured that providers are relying on the best available evidence that
medical science can offer and using the most appropriate technology to ensure improved
effectiveness and patient safety”.2 To respond to these pressures, hospitals need to clearly
define their vision, strategic goals and to have a good understanding of the threats and
opportunities in their environment and the hospital’s strengths and weaknesses. Hospitals strive
to continuously improve the quality and efficiency of their services and thereby contribute to
strengthening health systems.
Responsive
governance
Staff
orientation
Efficiency
Clinical
effectiveness
There is a need for building bridges between hospital staff and establishing a common
understanding of the hospital’s vision. If the hospital as a whole wants to succeed and reach its
long-term goals, a holistic view is needed that embraces different performance dimensions. The
Performance Assessment Tool for Quality Improvement in Hospitals (PATH) provides hospitals
with such a comprehensive and integrative, yet standardized tool to assess their performance,
to question their own results and to translate them into quality improvement activities by using
shared practices from other hospitals.
Safety
Patient centeredness
1
2
For further information see http://www.euro.who.int/healthsystems/Conference/.
WHO Regional Office for Europe (2008). The Tallinn Charter: Health Systems for Health and Wealth.
Copenhagen, WHO Regional Office for Europe.
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What is PATH?
The PATH system is a comprehensive tool for hospitals to assess their performance, to
question their own results and to translate them into quality improvement activities by using
shared practices from other hospitals. By participating to PATH, hospitals join a network that
shares a number of core values and commitments such as transparency, openness and
collaboration and continuous improvement; those are made explicit in the Vienna Statement on
Performance Assessment in Hospitals3. Participating hospitals recognize that performance
management is complex and needs to be addressed by the strategic decision-makers within
hospitals as well as on the operational level by all hospital staff. The PATH system goes beyond
the traditional professional divisions such as financial performance vs. clinical effectiveness; it
builds on a comprehensive view that embraces clinical effectiveness, efficiency, staff
orientation, responsive governance, safety and patient centeredness.
Starting with performance measurement, PATH encourages
hospitals to learn about their strengths and weaknesses and
to initiate improvement activities that ultimately help to fulfil
the hospital’s mission. This is achieved through a holistic view
of hospital performance that roots in a wide scope of performance indicators. If hospitals want to reach their long-term
goals, they need an integrated system to monitor their progress against a set of performance indicators linked to their
strategic goals. PATH is able to provide such a system and
can help to produce a new picture of participating institutions
PATH newsletter Vol. 2
that brings together hospital staff around various perspectives
on quality. PATH includes not only a performance
measurement tool, but also focuses on the interpretation of results in the strategic context of
each hospital. PATH helps hospitals to identify best practices in the field through benchmarking
with other hospitals in its network. PATH facilitates contacts between hospitals and
professionals and initiates learning activities.
“It is not all about publishing
figures, because if none of
them are using them – then
it is pointless. So this is
about to take it to the next
step – to actually using the
data to improve quality
care.”
How was PATH developed? – The past
The Performance Assessment Tool for quality improvement in Hospitals (PATH) was initiated by
the WHO Regional Office for Europe in 2003. The PATH system was created by a group of
international experts based on an extensive review of the literature and a survey on the
importance, usefulness and data availability of potential indicators in 20 European countries.
The system was pilot tested by 66 hospitals from 5 different countries between February 2004
and March 2006. Using the experiences of Country Coordinators and hospitals, PATH headed
for a second wave of data collection with a slightly reviewed indicator set, starting in 2006. In
this second phase, 140 hospitals from 9 different countries committed themselves to a change
for quality, collected data on 17 indicators and shared their experiences with other hospitals.
Lessons learnt
PATH has proven to be an excellent tool for
initiating performance assessment activities in
hospitals. It can lower the “barrier to entry” to
performance measurement systems by providing a
toolbox that is built on best available evidence with
leading partner organizations; hospitals or countries
3
“There was high agreement among
hospital coordinators that PATH is a
useful tool to (i) raise awareness on
different quality dimensions, (ii) address
interrelations between indicators and
(iii) integrate different databases in the
hospital.”
Groene et al. 2008
Vienna Statement on Hospital Performance, July 4 2008 (see appendix 1)
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benefit from this major piece of research and development (R&D). PATH was also used as a
tool to integrate and make sustainable existing national initiatives.
“One of the benefits of
participating in PATH stated by
regional/country coordinators
was that the PATH conceptual
framework facilitated
integrating different quality
assessment activities (…) and
led to improved knowledge on
data systems available in the
hospital (…).”
Groene et al. 2008
Probably the most visible impact was on raising awareness on – for instance – accountability, some overlooked
dimensions of performance, the role of indicators for evidence-based management, gaps in health information
systems and infrastructure for data collection but also
potential to better use the data readily available, and on
some specific issues. Indicators with the most impact were
probably the one for which ad-hoc data collection was
needed. Those indicators raised awareness to crucial
issues of quality (e.g. audit of medical records to assess
compliance with antibioprophylaxis guidelines, patient
survey based on the “health care transition measure” tool,
monitoring of the occupancy of the operating theatre).
In several instances, country coordinators (Ministry of Health, Health Insurance Fund)
developed through PATH a privileged partnership with participating hospitals that had a very
positive impact for acceptance and collaboration in the frame of other activities (e.g. quality
contracts, fee for performance).
The main limitations were related to validity concerns of “[It] inspired the hospital staff to
international comparisons (with regards to major local regard the operation room
adaptations) and untimely feedback of data. Data environment more widely and from
management is not a specific feature of PATH, nor a strong a more patient-oriented angle.”
asset of PATH. A centralized web-based data submission
was not achieved during the second wave of data Jane Alop, Estonia in PATH
newsletter Vol. 3
collection. To build an internet platform for data entry would
suppose major investments and result in a high fee for
hospitals. Also, the system would be more rigid, more difficult to adapt locally. Most importantly,
centralized data analysis for all countries was made extremely difficult because of the lack of
direct contact with hospitals (mostly because of language constraints) and the lack of
knowledge of local context, sources of data and potential bias related to data collection
procedures. Standardization and improved validity of data to enable international comparisons
are to be considered as long-term objectives. In countries that choose PATH to “lower barrier to
entry” for performance assessment activities, the first role of PATH will be to help with setting up
the infrastructure for data collection. Also, even if comparing results across countries might
make sense when prerequisites regarding standardization and validity are met, local
evaluation will always remain paramount.
The way forward? – PATH’09
The cornerstones for implementation of PATH’09 are local ownership, clear positioning of PATH
in relation to a national (or regional) strategy for quality improvement and/or for increased
accountability, and development of local capacities. Harmonization and building synergies are
additional cornerstones to PATH’09. It will work in close partnership with leading international
organizations in the various domains of performance to act as an “umbrella”.
PATH provides hospitals with four major features: a conceptual framework for performance
assessment, a toolbox (indicators and manuals), individual reports and a national (or regional)
network. The first two components are generic. They are proposed by WHO Regional Office for
Europe and freely available to all. The last two components are to be integrated into the local
context.
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PATH is built on a comprehensive framework for performance assessment that includes six
dimensions of performance and fosters a culture of measurement and evidence-based
management, cross-department dialogue, and integration of databases. It raises awareness to
the strategic role of hospital top management for performance management and to components
of performance that are sometimes overlooked.
The toolbox includes a single set of evidence-based indicators including clear definitions of
each indicator, a review of the current literature and suggestions on how to position these
indicators in the global perspective of hospital management. These indicators are harmonized
with best practices and were developed in collaboration with leading partner organizations in
each respective domain of expertise. PATH also provides hospitals with data collection tools
(e.g. survey questionnaires). Compared to previous waves, the set of indicators is reviewed for
PATH’09 with more possibilities for prospective data collection, as the pilot phase highlighted
that those often have more impacts and provide more reliable and comparable data. Data will
be collected over a limited period of time and it is not requested to collect data for all indicators
– but at least one per dimension – so that burden of data collection remains acceptable.
The responsibilities for data analysis, reporting of individual results to hospitals, and enhancing
networking among hospitals, lie at the country4 coordinator level. Suggested mechanisms for
national or regional networking include for instance newsletter, forum on website, twining,
working groups, workshops or national conference. Some country coordinators might develop
partnerships to exchange results to enable international comparisons on some indicators or to
establish common tools for international networking among their hospitals. We believe such
“regional networks” or “thematic networks” will emerge and will serve as a basis for building an
international association of hospitals (on a model similar to “Health Promoting Hospitals”network5) in the future.
PATH’09 recognizes and encourages the rapid evolution
towards more accountability of hospitals. Accountability and
transparency are core principles of WHO6 and a number of
countries have set up or are in the process of setting up
incentives to encourage quality improvements (e.g. accreditation mechanisms, performance contracts, public reporting). In this frame, PATH is providing a sheltered environment for hospitals in which to build a culture of measurement.
Through PATH and the experiences with data collection,
hospitals newly acquainted to performance measurement will
be able to identify deficiencies in their information management and be encouraged to improve their information
strategy. In addition, hospitals and national or regional stakeholders (e.g. Ministry of Health, Health Insurance Funds) are
invited to go further and engage into a collaboration to build
some accountability mechanisms around participation to
PATH or around PATH results – provided some minimum
requirements on data quality and independence of the PATH
national Country Coordinator are met.
4
5
6
“Although the original aim of
the PATH project is the
internal self-evaluation and
the support of managerial
activities within individual
hospitals, the comparison
among hospitals at national
level as well as international
benchmarking is expected
and welcomed.”
Workshop on Performance
and Quality Indicators for
Institutional Health Care,
Slovakia, 2007 in PATH
newsletter Vol. 3
“Country coordinator” is a generic term that we use for ease of reading. As PATH can be
implemented in single provinces or regions, there might be regional or provincial coordinators in
those contexts.
For further information see http://www.euro.who.int/healthpromohosp.
WHO (2005)
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Why is PATH different?
PATH embraces a comprehensive view on hospital performance that goes beyond fragmented
collection of performance indicators. This makes PATH a unique tool for strategic decision
makers in hospitals as they get a broad overview of the strengths and weaknesses of their
hospital as a whole. The multidimensional approach facilitates a direct linkage between the
hospital’s strategic objectives and the different quality indicators. In the meantime, the performance indicators of the PATH model are standardized tools which are consistent with other
international projects and allow for concrete active improvement activities at the operational
level. They are used for mutual learning through active networks in national and international
environments.
PATH clearly supports hospitals that are in the early stages of performance assessment and
helps them getting ready for the future. For participation, PATH only demands data for a limited
number of indicators, at least one indicator per dimension. Each dimension will have several
indicators ranging from low to more complex data collection procedures which can fit different
needs of hospitals. As hospitals may choose their indicators of interest, PATH should be an
attractive system for experienced hospitals as well as newly acquainted institutions in the
context of performance assessment. Furthermore, for all indicators, specific data collection tools
will be provided to facilitate and standardize data collection that will create more and more
possibilities for international comparisons.
PATH is not only about performance measurement, it encourages a continuous learning and
evaluation process in hospitals through a very active network. PATH provides a mutual learning
environment for participants where they can openly share their experiences and identify
international best practices. Through PATH collaborations with leading national and international organizations, participating hospitals do not only access indicators harmonized to
currently best available practices, but they can also benefit from facilitated access to networks,
experts, diagnosis tools within our partner organizations.
“Use of antibiotics increases the hospital costs,
therefore it is economically essential for the
management to monitor the indicator closely. A
young manager for infectious control of a hospital
became so enthusiastic that it was decided to go
further and also monitor the complications of
surgical patients within a year after an operation.
That is an excellent example on how the
implementation of one PATH indicator has evolved
into a wider improvement of quality.”
Jane Alop, Estonia in PATH newsletter Vol. 3
“On the national level, PATH
has been the first initiative in
Poland to collect data on
hospital performance not for
reimbursement or
administrative purposes but for
the voluntary improvement per
se. With many hospitals
enrolled, we perceive PATH as
the first national campaign
aiming at the potential
healthcare quality
improvement.”
A view from Krakow in PATH
newsletter Vol. 3
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What are PATH’09 products and services?
PATH’09 provides hospitals with a toolbox that includes the following components.
Tools
Description
Indicator set
The set comprises only a limited number of indicators, which are
internationally recognized as best practices regarding performance
assessment. They are harmonized with other quality improvement
projects used in the field and aligned to initiatives by international
professional organizations and associations of experts. On the one
hand, this decreases the burden of data collection and on the other
hand assures high quality of indicators. Each indicator includes a clear
definition and a review of the current literature that derive from the
partner organizations. The indicators relate to the six dimensions of
performance: clinical effectiveness, staff orientation, efficiency,
responsive governance, safety and patient centeredness. It includes a
sub-set of the formerly “core” and “tailored” indicators set (described in
previous rounds of PATH) as well as new indicators. On one side, for
most indicators, prospective data collection is preferred. Indeed, one of
the major lessons learnt from previous rounds is that prospective data
collection has a greater potential to really impact on practices (because
greater potential to make staff sensitive about some aspects of
performance sometimes overlooked) and that it is necessary to allow
for international comparisons. On the other side, hospitals are invited to
measure against all indicators but it is only required to measure against
one indicator for each dimension of performance. Hence, burden of
data collection remains within acceptable levels.
Data collection tool
Most indicators suppose prospective data collection. Standard
Operating Procedures for data collection include descriptions for each
indicator, a data collection sheet, and specific directions on when,
where and how to collect the data. Past experiences have shown that
these tools are crucial for the successful execution of data collection.
To further standardize the assessment of patient and staff experiences,
a limited number of surveys will be proposed to hospitals. The
establishment of this common ground will substantially increase data
quality.
Guidebook for
performance
management
The guidebook helps to relate the PATH results to the strategy of each
hospital. Essentially, it provides suggestions on what to do next.
Performance measurement is only the first step on the way to better
quality and needs to be followed by improvement efforts that create
value for the hospital and serve its ultimate goals. The process of
identifying a hospital’s strategy and linking it to performance assessment will help participants to get the most out of its resources invested.
Feedback report
The report will be computed and edited by the country coordinators. It
positions the results of each hospital nationally. It includes an overall
presentation of the hospital’s performance that helps to identify quickly
where the hospital is strong and where it most needs to improve. It also
provides a detailed report on every indicator that may help mainly
health care professionals to identify strengths and weaknesses in their
specific services and start quality improvement activities at the
operational level.
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Who can participate?
Hospitals of any type from European as well as non European countries are welcome to
participate on an annual basis. There is no limitation on the size, ownership or specialization of
the hospital as long as it provides data on a minimum of one indicator per performance
dimension. However, hospitals should be aware that indicators were designed primarily for
acute care general hospitals. Participating institutions should commit themselves to the
philosophy of the project and a long-term effort for improved quality.
The efficient fulfilment of the function of Country Coordinators has proven to be crucial for the
success of PATH in the past. If PATH is to be used for accountability mechanisms (e.g.
accreditation, pay for performance), in this particular case the Country Coordinator must be
independent from the regulator that is actually setting up those mechanisms (e.g. Ministry of
Health, Health Insurance Fund). If the results are for internal use of the hospitals only, Country
Coordinators may derive from the institutions mentioned above.
The country (or regional or provincial) coordinators have a key role for running their local
PATH network. They work together with the hospital coordinators to agree on 1) a calendar and
the scope of their collaboration, 2) on a set of core indicators for the country (or region) that
includes part of the PATH indicator set but could also include some local indicators, 3) on
procedures to report data to the country coordinators, 4) on ownership of data and scope of use
of data by other stakeholders. Country coordinators provide direct support to hospitals for
smooth and harmonized data collection and are responsible for assessing data quality, data
mining, and contact with hospitals to correct data if some irregularities are observed and for
calculating the indicators and reporting the individual results back to the hospitals. They also set
up mechanisms to facilitate networking among hospitals.
Those activities suppose substantial staff time and hence the country coordinator might need to
raise financial resources to realize his role. Sources of funding are diverse. They might include
support from Ministry of Health, Health Insurance Funds, hospital associations, research
institutes, or fees directly paid by hospitals to cover the costs of predefined services.
It is critical that country (or regional) coordinators develop a sound partnership with participating
hospitals and that hospitals feel confident to share their data and expose their current practices.
Country coordinators should also be recognized for their expertise and be considered leading
figures in the field of quality management.
Country coordinators assess data quality, they acknowledge that indicators are merely flags that
need to be interpreted with caution, and they communicate adequately to ensure that the
limitations are understood by all partners.
If requested, technical assistance will be made available to country (or regional) coordinators.
Technical assistance will be provided either directly from the WHO as part of the Biennial
Collaborative Agreement (BCA) activities, either from partners within the PATH network (e.g.
the WHO Collaborating Centre in Krakow). The conditions for technical assistance will be
discussed individually with each country coordinator and head of WHO country office when
setting up the PATH infrastructure in the country.
High level hospital representatives are asked to commit the institution to the Vienna
Statement on Performance Measurement in Hospitals (see appendix 1), ensure information and
motivation of the hospital staff in all departments, ensure high visibility of PATH at all levels of
the institution, and appoint a member of the hospital staff as PATH hospital coordinator.
It is suggested that the Hospital Coordinators should be highly credible in their institution and
have good coordination and management skills as they would have to deliver the following
functions:
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liaise with PATH country coordinator,
inform and train hospital staff,
“PATH was a great tool to
coordinate PATH data collection on-site,
convey a message on the
prepare technical set-up for PATH data collection,
multidimensional nature of
ensure internal data validation procedures,
performance and to foster a
execute PATH data transmission according to culture of self-evaluation for
schedules on PATH national level
improvement with all each
ensure adequate internal communication of feed- levels feeling accountable for
back reports and internal disclosure of performance performance in the hospital.”
results to hospital staff,
coordinate internal discussion and decision-making Implementing PATH in Belgium
PATH newsletter Vol. 1
on appropriate reaction to performance results,
promote management measures to be taken in
reaction to conspicuous performance results,
and organize for instant alert communication (“rapid response”) with PATH country
coordinator if required.
What are the next steps?
As a first step, a potential country coordinator should be identified. The country coordinator – in
collaboration with WHO country office in your country and, if relevant, other stakeholders – is
asked to draft a strategic note clarifying
1) Objectives and Environment: What are the objectives? What is the added-value of
PATH in your context? What are the other initiatives in the field in your country? How
does PATH fit in (bring in synergies or competition)? What are the incentives for
hospitals to participate?
2) Country coordinator and other institutional stakeholder and distribution of roles and
responsibilities
3) Potential hospital participants (full scale or limited to pilot site? Or to some specific
hospital categories?)
4) Human and financial resources available
Participation is open to all. Hospitals are only requested to commit to measure at least one
indicator for each dimension. If the number of participating hospitals is very limited in a country
or if no country coordinator can be identified, WHO CC in Krakow might provide support to
contact country coordinators within your region to potentially “absorb” a limited number of
hospitals across the border.
If you wish to discuss how to position PATH in your country and the next steps or to receive
additional information, please do not hesitate to contact Ann-Lise Guisset at the WHO.
Contacts
Ann-Lise Guisset
World Health Organization
Regional Office for Europe
Country Policies and Systems (CPS)
Basia Kutryba
WHO Collaborating Centre for Developing
Quality and Safety in Health Systems
PATH International Secretariat
Scherfigsvej 8
DK-2100 Copenhagen Ø
Denmark
Syrokomli 10
30-102 Krakow
Poland
Phone: + 45 39 17 12 54
Fax: + 45 39 17 18 18
E-mail: agu@euro.who.int
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Phone/Fax:+48 12 427 82 51
E-mail: who.krakow@cmj.org.pl
References
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Groene O et al. (2008). The World Health Organization performance assessment tool for quality
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Qual Health Care, 20: 155-161.
Performance Assessment & Quality Improvement, Newsletter Vol. 1-3,
(http://www.pathqualityproject.eu, accessed 02 June 2008).
Shaw C (2003). How can hospital performance be measured and monitored? Copenhagen,
WHO Regional Office for Europe (Health Evidence Network report;
http://www.euro.who.int/document/e82975.pdf, accessed 19 May 2008).
Veillard J et al. (2005). A performance assessment framework for hospitals: the WHO regional
office for Europe PATH project. Int J Qual Health Care, 17:487-96.
WHO Regional Office for Europe (2003). Measuring hospital performance to improve the quality
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WHO Workshop in Barcelona, Spain, 10-11 January 2003. Copenhagen, WHO Regional Office
for Europe.
WHO Regional Office for Europe (2003). Measuring hospital performance: Defining sub
dimensions and a framework for collecting evidence-based indicators. WHO Workshop in
Barcelona, Spain, 21-22 March 2003. Copenhagen, WHO Regional Office for Europe.
WHO Regional Office for Europe (2003). Selecting a core set of evidence-based hospital
performance indicators for enhancing quality improvement and evidence-based management.
WHO Workshop in Barcelona, Spain, 13-14 June 2003. Copenhagen, WHO Regional Office for
Europe.
WHO Regional Office for Europe (2003). Final elaboration and strategies for expanding the use
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Barcelona, Spain, 12-13 September 2003. Copenhagen, WHO Regional Office for Europe.
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