Co-Constructing Performance Indicators in Home and Community Care: Assessing the Role of Nongovernmental Organizations in Three Canadian Provinces

INTRODUCTIONCanada is not alone in its interests in performance measures. Many countries, including the UK, Australia, and the USA, and international organizations, such as the World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD), have developed performance tools with the goals to enhance effectiveness, equity, efficiency, and quality as well as to meet the public's demand for increased transparency and accountability from their public institutions (Aboriginal Health & Medical Research Council of New South Wales, 2013; Arah, Klazinga, Delnoij, Ten Asbroek, & Custers, 2003; McLoughlin, Leatherman, Fletcher, & Owen, 2001; McPake & Mills, 2000; Pal, 2000). As Paul Thomas (2006) aptly expressed, performance measurements achieved popularity in large part to address serious "democratic deficits," (p. 6)-a decline in legitimacy and public confidence in political institutions along with other financial, social, and performance deficits.This article examines the extent to which public servants interact with non-governmental organizations (NGOs) to co-construct performance indicators in the home and community care sector. Based on 32 extensive qualitative interviews with NGO representatives and public servants in three Canadian provinces (British Columbia, Saskatchewan, and Ontario) with distinctive home and community care systems, the study uncovers the experiences of NGO-government interactions. Specifically, it seeks to understand the role of NGOs in determining performance indicators by asking why performance indicators matter, what hand NGOs have in shaping them, under what contexts, and to what effect? Determining the appropriate indicators for the home and community care sector can play an important role in influencing the future direction of provincial healthcare systems, especially as the Canadian population ages. Varying funding and delivery models of home and community care across provinces put NGOs in different roles in the delivery of home and community supports, setting different contexts for NGO-public servant interactions across the three provinces. This article takes these different contexts into account in assessing how, and to what extent, NGOs influence the nature of performance indicators.The literature offers a number of common definitions of performance indicators. According to Jan Mainz (2003) indicators are:measures that assess a particular health care process or outcome; quantitative measures that can be used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes, and measurement tools, screens or flags that are used as guides to monitor, evaluate, and improve the quality of patient care, clinical support services, and organisational function that affect patient outcomes. (p. 524)Les Pal (2014) offers a more succinct definition: performance indicators refer generally to "some measure of how well a service or activity is doing, either through financial or output measures or client satisfaction" (p. 174). Researchers have long posed questions around the validity, reliability, impact, and scope of performance indicators in health. For example, there are ongoing debates regarding what can be measured, depending on how narrowly or broadly we define healthcare and our responsibility for it: how performance is conceptualized and measured (Arah et al., 2003); whether the emphasis is on "process" or "outcomes" (Mant, 2001; Steele Gray, Berta, Deber, & Lum, 2014a, 2014b); whether "quality" takes on a multidimensional nature, hence, requiring multiple measurement dimensions (Aboriginal Health & Medical Research Council of New South Wales, 2013); whether client preferences are part of the cost equation (Donabedian, 1988); how performance data are used; which stakeholder viewpoints should hold sway since different stakeholder have different views as to what processes or outcomes should be measured and how (Arah et al. …