Managing the performance of healthcare networks: a ‘dance’ between control and collaboration

Figures & data

Table 1. Participant demographics.

Demographics	Percentage
CCO REPRESENTATIVES
Role
Administrative	85% (50/59)
Clinical (i.e. provincial clinical leads)	15% (9/59)
Department/Portfolio
Clinical Programs and Quality Initiatives (cancer only)	36% (21/59)
Ontario Renal Network (renal only)	22% (13/59)
Prevention and Cancer Control (cancer only)	17% (10/59)
Planning and Regional Programs (cancer only)	15% (9/59)
Corporate Executives & Corporate Strategy (cancer and renal)	10% (6/59)
NETWORK REPRESENTATIVES
Type of network
Cancer	59% (52/88)
Renal	41% (36/88)
Role
Administrative	74% (65/88)
Clinical (i.e. network clinical leads)	26% (23/88)
Cancer network performance ranking on scorecard (Fall 2017)*
Low (ranked 11–14)	29% (4/14)
Medium (ranked 5–10)	43% (6/14)
High (ranked 1–4)	14% (2/14)

Renal networks are not ranked on their overall performance; rather they are ranked on an indicator-by-indicator basis.

Figure 1. A theoretical framework of network governance ambidexterity in the context of a NAO-governed, network-level performance management system involving both control and collaboration.

Table

PM Intervention	Description
Guiding*
Network administrative and clinical leadership model	Administrative leaders are embedded in host hospitals and are employees of, and therefore accountable to, both their host hospital and CCO. Each clinical program within CCO has a ‘clinical lead’ counterpart within each network. Clinical leads are paid by CCO for one day per week.
Funding contracts	Specify expectations for patient volumes, data submission, and implementation of provincial quality improvement initiatives. Some funds may be withdrawn for non-compliance with these performance expectations/deliverables.
Monitoring*
Scorecard	Generated quarterly to grade performance for each network (green, yellow, red) relative to each indicator and its target, and to rank performance of each network relative to others (global ranking in cancer for overall performance versus ranking per indicator in renal)
Annual Monitoring Report	Generated annually to monitor indicators retired from the scorecard (cancer only).
Web-based access to performance data	Secure, web-based database and analytic tools offer historic, current, and projected data on indicators; updated monthly and allows users to generate reports on specific queries.
Public reporting	The Cancer System Quality Index, a web-based public reporting tool on cancer system performance across 30 indicators. Select renal indicators are also reported on the Ontario Renal Network website.
Improving*
Quarterly performance review reports	Issued quarterly in preparation for quarterly meetings (below) and includes scorecard indicators as well as additional indicators; if performance is below target or declining for any given indicator, requires commentary on contributing factors and improvement plans; space also provided to summarize successes
Quarterly performance review meetings	Held between CCO leaders and network leaders following each quarter. Occurs via video-conference in cancer system and tele-conference in renal system. Performance results for the past quarter are discussed as well as data quality or reporting problems, success stories, challenges, and plans for improvement.
Recognition certificates	Issued annually for each indicator for networks that met target, were the top performer, and/or were the most improved.
Escalation process for poor or declining performance	Commences with an informal conversation with network leadership regarding performance, and may progress to a formal letter with template to complete a required improvement action plan and, in rare cases, to withdrawing of funds associated with requirement, if relevant.

*Tripartite framework of PM functions adapted from Smith (Smith 2002).

Table

Inductive Codes	Empirical Themes	Conceptual Categories
Codified performance requirements and deliverables in the NAO’s performance contracts with networks Codified criteria for funding withdrawal in escalation policy	Codified requirements and sanctions	Structural Ambidexterity
Codified expectation of collaborative indicator development/selection Codified expectation of collaborative problem-solving of performance issues Codified expectation of collaborative quality improvement	Codified expectation of collaboration
Codified differences in mission between NAO (oversight and funding) and networks (service delivery) in law Codified accountability to both their organization/network and NAO in leaders’ employment contracts	Codified NAO-network interdependence
NAO identifies expectations NAO monitors performance in relation to expectations NAO provides performance feedback NAO applies rewards and sanctions	Performance management establishes accountability	Goal Ambidexterity
NAO provides comparative data and rankings NAO links networks to each other to support learning and mentorship for quality improvement NAO requires improvement plan in escalation policy	Performance management enables improvement
Accountability is the foundation Improvement is the ultimate aim	Accountability in service of improvement
NAO requires work plans NAO mandates initiatives and tools NAO monitors performance in relation to targets Networks experience pressure to perform NAO rarely withdraws funding NAO sets up feedback mechanisms for networks to share successes and challenges NAO perceives networks as partners Networks perceive NAO as supportive and responsive	NAO exercises control with a collaborative tone	Behavioural Ambidexterity
Networks want support from NAO to interpret performance data Networks want support from NAO to identify solutions to performance problems	Networks request collaborative behaviours
Networks request escalation letters Networks request punitive word choice in quarterly performance review meetings Networks request retaining current volume of performance indicators	Networks request controlling behaviours

Smith, P. C. 2002. “Performance Management in British Health Care: Will It Deliver?” Health Affairs 21 (3): 103–115. https://doi.org/10.1377/hlthaff.21.3.103.

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Data availability statement

The data underlying this article will be shared on reasonable request to the corresponding author.