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What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change
  1. Jean-Frederic Levesque1,2,
  2. Kim Sutherland1
  1. 1 Bureau of Health Information, BHI, Chatswood, New South Wales, Australia
  2. 2 Centre for Primary Health care and Equity, University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Dr Jean-Frederic Levesque; jeanfrederic.levesque{at}


Objective Across healthcare systems, there is consensus on the need for independent and impartial assessment of performance. There is less agreement about how measurement and reporting performance improves healthcare. This paper draws on academic theories to develop a conceptual framework—one that classifies in an integrated manner the ways in which change can be leveraged by healthcare performance information.

Methods A synthesis of published frameworks.

Results The framework identifies eight levers for change enabled by performance information, spanning internal and external drivers, and emergent and planned processes: (1) cognitive levers provide awareness and understanding; (2) mimetic levers inform about the performance of others to encourage emulation; (3) supportive levers provide facilitation, implementation tools or models of care to actively support change; (4) formative levers develop capabilities and skills through teaching, mentoring and feedback; (5) normative levers set performance against guidelines, standards, certification and accreditation processes; (6) coercive levers use policies, regulations incentives and disincentives to force change; (7) structural levers modify the physical environment or professional cultures and routines; (8) competitive levers attract patients or funders.

Conclusion This framework highlights how performance measurement and reporting can contribute to eight different levers for change. It provides guidance into how to align performance measurement and reporting into quality improvement programme.

  • quality improvement
  • performance measurement
  • healthcare system change
  • conceptual framework

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  • Contributors J-FL generated the original idea, presented the original ideas in scientific plenaries, participated in the scoping of the literature, conceptualised the framework and drafted the manuscript. KS participated in the scoping of the literature and in the conceptualisation of the framework and drafted the manuscript. Both authors deliberated the findings and produced the discussion of the manuscript and revised the manuscript following reception of comments from peer reviewers.

  • Competing interests None declared.

  • Ethics approval This work was conducted without direct contact with patients or providers, representing a synthesis of published academic and grey literature.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.