Need to evaluate management Control the costs Fulfill new requirements Greater demandings Creation of information systems that allow to grade the management [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June

In a general way… …measurement units to monitor and evaluate through comparison between different entities …are… Two main functions EvaluateDescribe [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June

Efficiency Efficacy Effectiveness Cost-efficiency Comparability Availability Relevance Consistency Reliability [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June [4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005

Lack of technical means Input/Output measurement difficulties Availability of funding Employees lack of instruction Little dynamism from commissions responsible for executing indicators Inadequacies of information systems [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June [4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005

Facing an inefficient and non productive governmental management of public health systems Construction of evaluation means for the efficiency and effectiveness levels of health systems [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June

Comparative quality reporting Public reporting Pay-for-performance Public reporting Pay-for-performance Comparative quality reporting

The financing of Health entities is based on Diagnosis Related Groups (DRGs) Sorting systems for patients in clinically coherent and homogeneous groups – in a resource consumption point of view Built from the diagnostic features and patients therapeutic profiles that explain the resource consumption in hospitals Tendency to rationalize the funds distribution process [5] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar. Revista Gestão Hospitalar December-1997 January;33:

Norte Centro Lisboa Alentejo Algarve Região Autónoma dos Açores Região Autónoma da Madeira Establish a comparison between the different areas of Portugal Compare the numbers from 2000 to 2007 Evolution of the services quality and efficiency [25] Nomenclatura de Unidades Territoriais para fins estatísticos, Wikipédia, 2008 [26] Parlamento Europeu, Conselho da União Europeia. Regulamento (CE) N.º 1059/2003 do Parlamento Europeu e do Conselo, relativo à instituição de uma Nomenclatura Comum das Unidades Territoriais Estatísticas (NUTS), Jornal Oficial da União Europeia May 26.

Excluded episodes (ambulatory episodes): Planned admission Release date equals admission date Patients do not change hospitals Patients do not leave against medical advice nor die % Inpatient episode85,4 Ambulatory episode14,6 Database with inpatient episodes from 87 Portuguese public Hospitals between 2000 and 2007

Gender Male 44,4 Female 55,6 Age 1719, , , , , , ,2 7518,2 Nuts II Alentejo4,9 Algarve3,7 Centro26,0 Lisboa26,5 Norte33,8 Discharge Year , , , , , , , ,5 Total admissions:

HOSP_ID EPIS_ID SEXO DDX1-DDX20 SRG1-SRG20 DSP BIRTH_WGT ADM_TIP HOSP_FROM HOSP_TO TOTDIAS SAIDLAST DRG MDC RESIDE ENT1 HOSP_RESIDE DISTANCIA

Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Newborns Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Newborns Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Vaginal Deliveries Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Unspecified surgical procedures Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Medical DRGs complications Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Deliveries Unspecified surgical procedures Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal deliveries Unspecified surgical procedures Medical drgs complications

b) Establish a comparison between the different areas of Portugal a) Compare the numbers from 2000 to 2007

2000(%)2001(%)2002(%)2003(%)2004(%)2005(%)2006(%)2007(%) Exceptional admission episodes Short-term episode 19,219,419,719,8 20,319,719,8 Long-term exceptional episode 2,42,11,91,71,61,5 Complication-free long-term admissions 1) 1,3 1,00,8 0,60,50,6 Readmissions45,845,546,045,9 46,345,844,4 Newborns1,041,081,15 1,081,061,041,02 Vaginal Delivery Complications free75,576,471,374,873,976,772,973,5 With complications24,523,628,725,226,123,327,126,5 Unspecified surgical procedures13,412,612,313,012,612,411,711,8 Medical DRGs complications10,511,312,412,512,214,013,113,9 1) Calculated from a 1 % sample

Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9 Alentejo (%)Algarve(%)Centro(%)Lisboa(%)Norte(%) Exceptional admission episodes Short-term episode 16,618,318,621,319,8 Long-term exceptional episode 2,12,41,71,91,6 Complication-free long-term admissions 1) 0,81,40,9 0,8 Readmissions 78,677,675,376,775,3 Newborns 1,1 1,51,21,3 Vaginal Delivery Complications free 86,088,371,273,5 With complications 14,011,7 28,8 26,5 Unspecified surgical procedures 6,33,726,730,127,5 Medical DRGs complications 4,43,226,629,529,9

[1] Entidade Reguladora da Saúde. Relatório da Actividade Reguladora de 2007 [Internet]. Porto: 2008 August [accessed 2008 October 30]. Available from Reguladora% pdf/ view. [2] Ministério da Saúde. Diário da República [Internet] January 23 [accessed 2008 October 30]. Portaria n.º 110-A/ ª Série - N.º16. Available from [3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC June [accessed 2008 October 27]; N.º3. Available from /noticias/Confer Forum.htm. [4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet] December [accessed 2008 October 27]. Available from Dezembro-2005/ pdf. [5] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar. Revista Gestão Hospitalar December-1997 January;33: [6] Eddy D M. Performance measurement: problems and solutions. PubMed [Internet] July-August [accessed 2008 October 27]; 17(4):7-25. Available from EntrezSystem2.PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum. [7] Freeman T, Using performance indicators to improve health care quality in the public sector: a review of the literature. PubMed [Internet] May [accessed 2008 October 27]; 15(2): Available from pubmed/ [8] Collopy B T. Clinical indicators in accreditation: an effective stimulus to improve patient care. PubMed [Internet] June [accessed 2008 October 27]; 12(3): Available from PEntrez. Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum. [9] Thomson R G, Lally J. Performance management at the crossroads in the NHS: don't go into the red. PubMed Central [Internet] [accessed 2008 October 27]; 9: Available from picrender.fcgi?artid = &blobtype=pdf. [10] Agency for Healthcare Research and Quality (AHRQ). AHRQ Summary Statement on Comparative Hospital Public Reporting [Internet]. United States of America: Health and Human Services. [accessed 2008 October 27]. Available from: pdf. [11] Kondro W. The joys of quality indicators. Canadian Medical Association Journal January 15; 178(2): [12] Shojania K G, Forster A J. Hospital mortality: when failure is not a good measure of success. Canadian Medical Association Journal July 15; 179(2): [13] Machado M C S. O Plano Nacional da Saúde [Internet]. Portugal (PT): Alto Comissariado da Saúde. [accessed 2008 October 27]. Available from [14] Geraedts M, Schwartze D, Molzahn T. Hospital quality reports in Germany: patien and physician opinion of the reported quality indicators. Canadian Medical Association Journal September 28; 7: 157. [15] Galvin R S. Are performance measures relevant?. Health Affairs July-August; [16] McGlynn E A. Selecting common measures of quality and system performance. Medical Care January; 41(1 Suppl):I [17]Thomson R, Taber S, Lally J, Kazandjian V. UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development. International Journal for Quality in Health Care April; 16 Suppl:i51-i56.

[18] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de Grupos de Diagnósticos Homogéneos [19] Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; [20] Faúndes A, Pádua K S, Osis M J D, Cecatti J G, Sousa M H. Brazilian women and physicians' viewpoints on their preferred route of delivery. Revista de Saúde Pública. 2004; 38(4): [21] Reynolds A, Ayres-de-Campos D, Costa M A, Santos C, Campos I, Montenegro N, Influence of three organisational measures on the cesarean. Acta Médica Portuguesa. 2004; 17: [22] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de Grupos de Diagnósticos Homogéneos Mar. [23] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de Grupos de Diagnósticos Homogéneos Sep. [24] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de Grupos de Diagnósticos Homogéneos Aug. [25] Nomenclatura de Unidades Territoriais para fins estatísticos [Internet], Wikipédia, 2008 Dec 13 [accessed 2008 Dec 16]. Available from: [26] Parlamento Europeu, Conselho da União Europeia. Regulamento (CE) N.º 1059/2003 do Parlamento Europeu e do Conselho, relativo à instituição de uma Nomenclatura Comum das Unidades Territoriais Estatísticas (NUTS). Jornal Oficial da União Europeia May 26. [27] Ministério da Saúde. I Série-A. Diário da República Nov 5. [28]Pereira A C, Pinto A T, Parry G, Vieira P, Azevedo L F, Martins C, Vieira A, Desenhos de estudos [Internet]. Universidade do Porto, Serviço de Bioestatística e Informática Médica [accessed 2008 Dec 16]. Available from: numero=1&titulo=Desenhos+de+estudo. numero=1&titulo=Desenhos+de+estudo [29] Alto Comissariado da Saúde - Ministério da Saúde. Indicadores e Metas do PNS [Internet] [accessed 2008 Dec 10]. Available from: par=acs&lang=PRT#. par=acs&lang=PRT# [30] Sistema Nacional de Saúde. Indicadores de Desempenho 2004 – 2006 [Internet]. [acessed 2008 Dec 14]. Available from: