Performance measurement of district level hospitals in low income countries: Participatory development of an instrument to assess inputs, processes, and outputs for evidence-based management and quality improvement

BACKGROUND: The potential of hospital performance measurement (HPM) to contribute to improved quality of care and patient outcomes is underrepresented in the health system strengthening literature and no standardized HPM instrument exists for hospitals in developing countries. The problem centered Participatory Action Research (PAR) approach is particularly suited to addressing complex organizational problems in low resource settings and is gaining acceptance as an applied research method in healthcare settings.;METHODS: This quasi-experimental study using the PAR approach was carried out in 4 hospitals in Cameroon. Quantitative (415 surveys) and qualitative (129 interviews and 77 observations) methods examined how participating in the design of a HPM instrument influences health personnel's knowledge, attitude, interest, and intention to continue use of performance measurement for quality improvement. Changes in scores for the above outcomes from before and after implementation of the performance indicators were compared to scores from a non-participating control hospital at the same time points.;RESULTS: Personnel designed and pilot tested performance measurement indicators in all hospital services. Hospitals that actively participated in instrument design showed a statistically significant increase in HPM knowledge and attitude, and were more likely to report intention to continue using HPM as compared to the non-participating hospital. Hospital personnel participating in the design process were more aware of the workload barriers to implementing HPM but nonetheless were more motivated to continue the HPM effort. In addition, the PAR approach fostered ownership, increased skills, raised awareness of performance gaps, and led to a contextually appropriate tool.;CONCLUSIONS: The results of this study demonstrate the feasibility of designing and implementing an HPM instrument in a low-resource health care system and highlight the positive benefits of the PAR approach. Further research is needed to determine the effect of regular HPM on quality of care and its sustainability over time in resource constrained settings.