The problem with red, amber, green: the need to avoid distraction by random variation in organisational performance measures

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Many healthcare organisations now track a number of performance measures like infection and complication rates, waiting times, staff adherence to guidelines, etc. Our own organisation, The Capital Region of Denmark, provides healthcare for 1.7 million people and runs 6 hospitals and 11 mental health centres. Measures of clinical quality have been widely used in our region locally at hospitals and departments for many years. Recently, our region started to systematically define and track strategical key performance measures also at the top management level. Approximately 25 measures on a wide range of subjects from hospital infections to public transportation are being tracked by the top management and the Regional Council. The measurement strategy for hospitals involves a bottom–up approach allowing each hospital and department to, if needed, define its own performance measures that feed into one or more of the overall measures. For example, bacteraemia is one of the overall measures, and some acute-care departments, who rarely see hospital-acquired bacteraemia, have started to work on reducing the use of bladder catheters in order to reduce the risk of bacteraemia from catheter-related urinary tract infections diagnosed after their patients have been transferred to other departments. To support their work, they have developed a handful of measures that track the use of catheters and staff compliance with standard procedures related to catheter use. We welcome this development very much. The choice of relatively few overall measures combined with the bottom–up approach is a helpful strategy that focuses and aligns improvement work and stimulates the use of data at all levels of the organisation while leaving room for meaningful local adaptations of performance …