4 To meet these multiple demands, performance indicators (‘measurable elements of practice performance for which there is evidence or consensus that they can be used to assess the quality, and hence change of quality, of care provided’) and performance frameworks (‘conceptual frameworks that set out the rationale and design principles for an indicator set’) 5, 6 are typically designed to routinely monitor aspects of healthcare performance such as effectiveness, efficiency, safety and quality. 7 The quest for a single composite indicator of quality, prevalent in the early days of indicator development, has largely been abandoned in favour of multidimensional frameworks. 1 Indicator sets commonly contain a combination of structure, process and outcome assessments. The Organisation for Economic Co-operation and Development (OECD) publishes 60 internationally comparable indicators of healthcare quality. However, many countries, even those with advanced data systems, have difficulty linking practice performance to outcomes because of limitations in data availability and poor capabilities to link data. Notwithstanding these kinds of shortcomings, it is useful to assess the frameworks and performance indicators in a sample of countries for the insights this provides. Some health systems have moved faster than others in adopting performance indicators as tools for quality improvement and have made details of their indicators and systems for applying them publicly available at national, regional or institutional levels. We selected eight prominent health systems for review and assessment based on purposively selecting a sample that were exemplars in using indicators and making their data and performance systems available: Australia, Canada, Denmark, England, the Netherlands, New Zealand, Scotland and the United States. ![]() At the time of our review, all had made progress in selecting or applying indicators to measure or stimulate improved performance and most had developed a framework for conceptualising performance improvement or indicator use.
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