Measuring Performance Quality in Health Care: Relevance and Validity of the Frameworks

1.2.1 Conceptual frameworks for performance measurement

Various conceptual frameworks highlight that improving healthcare quality requires integrated strategies. These strategies often include patient assessments, evaluating health system operations, and focusing on key areas like safety, patient satisfaction, and overall healthcare effectiveness. Performance evaluation in health systems remains a critical issue globally, despite numerous efforts by governments, organizations, and healthcare providers to develop consistent measurement models [10]. Yet, there remains a lack of standardized frameworks, especially regarding the indicators and methods used for evaluation [11].

Over the years, several models have been developed to measure the quality of healthcare services [12]. These frameworks vary in terms of underlying principles and processes but share similar overall goals of improving healthcare standards [13, 14].

Performance measurement is considered an essential tool for driving continuous improvement in health systems. To be successful, the emphasis should be placed on patient-centered outcomes, strengthening the connection between quality measurement and accreditation systems, and advancing frameworks that help integrate existing models into practice. As noted by experts like Calva and McLean, while there is no conclusive proof that performance outcomes always lead to quality improvements, insights from other sectors suggest that performance measurement is vital for fostering change and innovation [15]. The role of quality measurement and accreditation systems will continue to grow in importance as healthcare systems evolve [16].

To ensure the consistent delivery of high-quality healthcare, it is critical to assess not only processes and outcomes but also patient experiences and the organizational frameworks that support care delivery. Shifting the focus from purely process measurement to outcomes that directly impact patients’ lives is key to improving healthcare quality [17].

The goal of performance measurement in healthcare is to (a) achieve continuous improvement by identifying opportunities for improvement and tracking progress against organizational goals; (b) compare performance by benchmarking against internal and external standards; and (3) achieve desired results, including assessing the extent to which healthcare services meet their intended goals and focusing on evidence-based outcomes or processes [18].

2.2.1 Study type

A qualitative analysis method was employed to synthesize and organize the results of full-text studies included in the review, based on three keywords: quality in healthcare, performance in healthcare, and performance measurement in healthcare. The research relied on databases such as MEDLINE, Google Scholar, Cochrane, and reference lists of studies to identify academic articles meeting the research criteria. The scope of the review was defined using a conceptual framework aimed at capturing factors relevant to performance evaluation in healthcare. Performance measurement and evaluation terms were combined using free text and guided terms. Only articles published in English and focusing on healthcare or community care were considered, while studies that did not address tools and mechanisms for measurement in healthcare were excluded. The review followed the steps outlined by Grant and Booth [19] in scientific research and adhered to PRISMA guidelines [20] for tracking published studies and descriptive analyses.

2.2.2 Qualitative data analysis

Thematic analysis was used, which consists of six steps: (1) Data familiarization: Reviewing and understanding the data; (2) Coding: Producing health-related codes for the data; (3) Theme identification: Identifying recurring themes; (4) Reviewing themes: Reviewing and refining the identified themes; (5) Defining themes: Clearly defining and describing the themes; (6) Report preparation: Structuring the findings into an organized report.

Articles were coded thematically to identify responses aligned with the selection criteria. Extracted data included theoretical foundations, measured constructs, and methods of development and evaluation of measurement properties.

2.2.3 Analysis stages

The selected studies were analyzed and categorized using the developed theoretical framework. Four stages were followed for data analysis: (1) collecting and categorizing information based on defined criteria; (2) analyzing obtained results; (3) creating comparative tables for existing conceptual frameworks; and (4) drawing conclusions and assessing performance for measurement frameworks.

3.2.1 Donabedian model (Donabedian A.)

In 1966, Donabedian pioneered the assessment of healthcare quality. His work led to the creation of the Donabedian model, which categorizes healthcare quality into three key components: structure, process, and outcome. The model considers both technical aspects of quality, such as efficiency and effectiveness, as well as functional aspects, including patient satisfaction. It is organized around four levels of evaluation: (1) the quality of care delivered by healthcare professionals; (2) the quality of the infrastructure used for patient care; (3) the benefits received by patients and their families; and (4) the quality of service delivery, focusing on access, continuity, and coordination of care.

3.2.2 Shortell et al. model

The Shortell model evaluates healthcare quality through four dimensions: strategic, cultural, technical, and structural [24]. The model highlights the importance of leadership, collaboration, and ongoing adaptation in driving performance improvements. It supports frameworks like the “patient-centered medical home” (PCMH) and the “accountable care organization” (ACO) [37]. Harrison et al. synthesized key elements from several influential frameworks, such as the Consolidated Framework for Implementation Research and the Socio-Ecological Framework, to address issues of patient orientation, care accountability, and population health management [38]. The model encompasses four levels of transformation: (1) individual patient responsibility; (2) teamwork and collaboration; (3) support for accountable care organizations; and (4) the environment in which care occurs [39].

3.2.3 Campbell et al. model

The Campbell model, building upon the Donabedian model, evaluates healthcare quality through two primary dimensions: access and effectiveness [26]. Effectiveness, in this context, includes both clinical outcomes and the personal relationships between patients and providers [35]. The model identifies four key outcomes: health status, patient evaluation, cost of service delivery, and equity. Additionally, it incorporates eight performance dimensions that include specific and non-specific skills, communication abilities (both written and oral), effort estimation, self-discipline, teamwork, supervision, and management.

3.2.4 Starfield model

The Starfield model focuses on four core principles of primary care: (1) first-contact access, which involves delivering timely care while minimizing barriers; (2) continuity, which emphasizes the ongoing relationship between patients and providers; (3) comprehensiveness, offering a wide range of services that address prevention, diagnosis, treatment, and rehabilitation; and (4) coordination, ensuring that healthcare services are integrated across different levels of care [5]. Derived features include accessibility, service range, and utilization. The model is grounded in core values such as equity, ensuring universal access to healthcare, efficiency, optimizing resource use, and effectiveness, ensuring care meets desired outcomes [40]. The Starfield model argues that a strong primary care foundation leads to better overall public health outcomes, reduced mortality, and diminished health disparities.

3.2.5 Kringos et al. model

Kringos’ framework defines the healthcare system as a multifaceted entity contributing to health outcomes through multiple dimensions. These include governance, economic conditions, workforce development, access to care, continuity, coordination, comprehensiveness, quality, effectiveness, and health equity [3]. The model aims to explore the interactions between these dimensions to assess how each contributes to health system performance. These dimensions ensure that healthcare is delivered efficiently and effectively, providing equitable access across all societal segments, including vulnerable populations.

3.2.6 Sicotte et al. model

This model focuses on four critical functions within healthcare organizations (HCOs): coordination, integration, control, and adaptation. These functions interact dynamically, resulting in a balance that affects organizational performance. The model’s strength lies in its ability to combine traditional performance models, offering a unified framework that captures multiple performance dimensions. For example, coordination ensures that resources and activities are efficiently aligned across different levels of care, while integration promotes collaboration across healthcare sectors. Control ensures the monitoring and regulation of performance through quality assurance and accountability mechanisms, while adaptation involves the organization’s ability to respond to internal and external changes, fostering long-term sustainability [41].

3.2.7 EGIPSS model

The Global and Integrated Evaluation of Health Systems Performance (EGIPSS) model is a comprehensive framework for assessing healthcare performance. It is based on principles such as efficiency, effectiveness, responsiveness, quality, access, and equity. The model emphasizes the need to align organizational functions—such as service delivery, resource management, and governance—through clear objectives and integrated processes. This alignment ensures that all parts of the healthcare system work cohesively to enhance outcomes. Performance is monitored through data-driven feedback, and flexibility is encouraged to adapt to emerging challenges like demographic shifts and health crises [42]. The model ultimately aims to enhance the system’s ability to respond to patient and community needs, ensuring equity and resilience in dynamic healthcare environments.

3.2.8 Kruk et al. model

Kruk et al.’s model provides a framework for evaluating primary healthcare systems based on four essential dimensions: effectiveness, efficiency, equity, and satisfaction. The model emphasizes the importance of using health information systems to assess performance and enhance quality across these dimensions [43]. By focusing on these four areas, the model aims to ensure that primary healthcare systems are meeting their health goals, utilizing resources efficiently, ensuring fair access for all populations, and achieving high levels of satisfaction from both healthcare providers and recipients [44]. This model emphasizes the need for integrated care processes that not only consider final outcomes but also the quality of care delivery.

3.3.1 World Health Organization (WHO) model

The World Health Report 2000 [45] identified four key functions in the health system: financing, service delivery, resource generation, and the administrative system, which includes oversight of both public and private sectors. The report also outlined three overarching goals for the health system: promoting good health for populations, ensuring responsiveness to public needs, and ensuring equitable financing mechanisms [10]. These goals aim to improve health outcomes, enhance system responsiveness to the expectations of populations, and promote financial fairness. The responsiveness of the system is built on two elements: (1) respect for individuals and (2) a client-centered approach.

Variations in performance are attributed to how the system organizes its core functions: governance, financing, service delivery, and resource generation. The WHO model emphasizes efficiency, which refers to the measurable outcomes of the health system’s performance. With growing concerns about safety in care, this model has become integral to discussions around healthcare reforms [46]. The WHO framework is grounded in six interconnected dimensions: clinical effectiveness, safety, patient-centered care, responsive governance, staff orientation, and overall efficiency.

3.3.2 American Institute of Medicine (IOM) model

The Institute of Medicine (IOM) model has long been a foundational framework for healthcare reform planning and assessing healthcare quality in the U.S. This model focuses on three primary goals: improving the personal care experience, enhancing population health, and reducing healthcare costs [47]. Five integrated components guide the model: partnerships with individuals and families, redesigning healthcare, population health management, financial management, and system integration.

The IOM’s emphasis on improving quality centers around six key dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity [30]. The framework promotes ongoing reevaluation and adjustment of strategies, policies, and programs to ensure that the system evolves to meet these goals effectively [48].

3.3.3 Agency for Healthcare Research and Quality (AHRQ) model

The AHRQ model focuses on measuring healthcare quality by identifying diagnostic error rates, determining the root causes of errors, and evaluating the effectiveness of interventions. To meet these objectives, the model relies on insights from stakeholders, including physicians and patients, utilizing data, measurement systems, health IT, and organizational factors [49]. It also highlights future research directions to further improve healthcare delivery and error management.

3.3.4 Canadian model

The Canadian healthcare system, as highlighted by Watson et al., is supported by substantial government contributions in terms of financial, material, and human resources [50]. The model emphasizes the importance of timely and accessible care, with a particular focus on primary care, team-based interdisciplinary approaches, chronic disease management, and healthcare sustainability.

In Canada, the key objectives of the healthcare model include ensuring (1) timely access to care, (2) efficient home and community-based services, (3) accurate health information for informed decision-making, and (4) the long-term sustainability of the healthcare system [51]. The model also evaluates primary care outcomes through metrics such as access, suitability, continuity, effectiveness, efficiency, equity, patient focus, and safety.

3.3.5 Organization for Economic Co-operation and Development (OECD) member countries model

The OECD model aims to compare healthcare quality across its member countries using a set of standardized indicators. The OECD health quality indicators project underscores the complexity of healthcare and the need for a balanced framework that integrates key concepts and performance dimensions. The model is divided into two components: healthcare service delivery and clinical care technical quality [52]. The objectives of measuring healthcare quality include improving overall performance and enhancing accountability.

Several key quality areas are identified by Arah and colleagues, such as access to services, care environment, expenditures, governance, efficiency, continuity, patient-centered care, safety, and timeliness. These indicators provide a comprehensive overview of healthcare performance, allowing for comparison across countries and systems [53].

3.3.6 Institute for Healthcare Improvement (IHI) model

The IHI model focuses on improving healthcare quality by implementing strategies that enhance the efficiency and effectiveness of services. The IHI developed a comprehensive system-level approach that includes a set of balanced measures to monitor quality of care across various healthcare organizations [54]. This system is closely aligned with the “Triple Aim” framework, which seeks to improve the patient experience, improve population health, and reduce healthcare costs [47]. The model includes essential components such as (1) patient-centered care, (2) collaboration among healthcare teams, (3) performance measurement through data analysis, (4) continuous learning, and (5) sustainable improvements in health outcomes. The goal is to reduce medical errors and enhance health outcomes through teamwork and ongoing improvements in healthcare delivery. The IHI’s approach provides a holistic view of care that encompasses patient participation, continuity, and preventive practices.

3.3.7 Australian national healthcare model

The Australian national healthcare model was developed to address two primary concerns: (1) effective resource allocation and (2) improving the quality of healthcare. The Australian Institute of Health and Welfare (AIHW) established guiding principles for performance indicators, which emphasize comprehensive and equitable access to healthcare services, a focus on prevention, and ensuring high-quality care in all settings. This model incorporates three levels of healthcare performance: (1) health status and outcomes, (2) health determinants, and (3) health system performance [55]. These outcomes are linked to various programmatic processes, with four primary levels of focus: governance, organizational structures and processes, care processes, and intermediate outcomes. Key dimensions in the Australian model include quality, equity, efficiency, effectiveness, access, safety, and continuity of care.