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Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability

Pross C, Geissler A, Busse R
The Milbank Quarterly, 95: 136–183
DOI 10.1111/1468-0009.12248


Policy Points:

  • Similarities and disparities between countries and initiatives are identified. Measuring, reporting, and rewarding quality is heavily focused on process measures. Hospital-level benchmarking is not always available publicly. Quality-related payment schemes vary widely, with several countries only piloting small-scale initiatives.
  • To increase quality accountability, the government has to set standards and incentives. The right balance between system centralization and decentralization has to be struck. Accountability needs to be based on outcomes, not process measures, and focus should be on hospital and medical condition levels. Providers have a central role as quality accountability advocates.


Studies have documented wide quality variation among hospitals within and across countries. Increasing quality-of-care accountability for hospitals, especially for patients and the general public, is an important policy objective, but no study has yet systematically and comprehensively compared leading countries’ initiatives in this regard.


Based on expert interviews and an extensive literature review, we investigate hospital quality accountability in England, Germany, the Netherlands, Sweden, and the United States. The underlying framework includes 3 elements: measuring quality, reporting quality, and rewarding quality. Each element is subdivided into 2 dimensions, with measuring composed of indicator type and data source, reporting composed of degree of reporting centralization and data accessibility, and rewarding composed of extent of application and type of quality-related payments.


The results show a wide spectrum of approaches and progress levels. Measuring strategies are more similar across countries, while quality reporting and financial rewards are more dissimilar. Reporting of process indicators is more prevalent than reporting of outcomes. Most countries have introduced some quality-related payment schemes, with the United States having the most comprehensive approach. Based on the cross-country assessment, 5 policy levers to enhance quality transparency are identified and illustrated through country-specific examples: (1) the government should take a central role in establishing standards and incentives for quality transparency and health IT system integration; (2) system centralization and decentralization need to be balanced to ensure both national comparability and local innovation; (3) health systems need to focus more on outcome transparency and less on process measures; (4) health systems need to engage providers as proponents of quality transparency; and (5) reporting should focus on hospital and condition levels to ensure comparability and enable meaningful patient choice.


The findings facilitate cross-country learning and best-practice adoption by assessing hospital quality accountability strategies in 5 countries in a structured and comparative manner. The identified policy levers are relevant for enhancing breadth, depth, and value of quality accountability.

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