Making performance indicators work: the experience of using consensus indicators for external assessment of health and social services at regional level in Spain

Objectives: To describe a methodology and the results of projects combining consensus processes for indicator development with methods of external assessment of health and social services. Methods: Our methodology can be characterized by a four-step approach: (1) stakeholder involvement and creating an enabling environment, (2) using standardized consensus methods for indicator development, (3) using rigorous external evaluation methods to assess results and (4) developing and implementing quality improvement initiatives. We describe each step in detail and discuss factors of success and pitfalls based on our experience of applying the methodology in 648 health/social centres and reviewing overall 68,616 case records. Results: We observe in four sectors (assisted living, elderly health care, care for people with drug abuse problems, and care for abused woman) improvements in overall quality improvement rates, ranging from 9.5% to 65.6%. Improvements in overall rates are accompanied by reduction in range of up to 48.8. Conclusions: The conscientious setting up of an enabling environment and the systematic involvement of professionals in designing indicators and setting standards is a key to improving performance. Our research may entail lessons for policy makers on the current debate on pay for performance models.