Outcome Based Accountability ‘From Talk to Action’ David Burnby

Fiscal Policy Studies Institute Santé Fe, New Mexico (publications)

Outcome Based Accountability 1 Language 2 Levels of Accountability 7 Steps from Talk to Action

Two Levels of Accountability Population Accountability about the well-being of WHOLE POPULATIONS for neighbourhoods – districts – regions - countries Performance Accountability About the well-being of CLIENT POPULATIONS for projects – agencies – service providers

1 Language Outcome –A condition of well-being for children, adults, families or communities Indicator –A measure which helps quantify the achievement of an outcome Performance Measure –A measure to evaluate how well a programme, agency or service system is working Population Accountability Performance Accountability ENDS MEANS

Population and Performance Accountability All Young People in (a place) WHOLE POPULATION OUTCOME: All Young People in (a place) are Healthy INDICATOR Obesity Rate Young people attending active lifestyle programme PERFORMANCE MEASURE % Young people attending losing weight Contribution Means End

Seven Steps from Talk to Action: The Leaking Roof Inches of Water Time Experience Measure Story behind the baseline (causes) Partners What Works? Action Plan (Strategy) Forecast Fixed? Not OK

OUTCOME “Healthy and Successful Adults” INDICATORS Measures of the outcome 1.All age, all cause mortality rate current smoking rate 3.Healthy life expectancy at Age 65 BASELINES Where we’ve been Where we’re going Where we want to be STORY Behind the baselines The causes, the forces at work What’s driving the baselines? PARTNERS With a role to play Public, Private and Voluntary Sector Community groups Residents WHAT WORKS What would it take to turn the curve? Best practice Best hunches ACTION PLAN What we propose to do, how and by when Data Development Agenda (Pt 1) Data Development Agenda (Pt 2)

The 7 Population Accountability Questions 1.What are the quality of life conditions we want for the children, adults and families who live in our community? 2.What would these conditions look like if we could see them? 3.How can we measure these conditions? 4.How are we doing on the most important of these measures? 5.Who are the partners that have a role to play in doing better? 6.What works to do better, including no cost/low cost ideas? 7.What do we propose to do?

The definition of the WHOLE POPULATION we want to impact on (e.g. “All young people in Hull” or “All older people in Middlesbrough” etc.) The desired OUTCOME: The condition of well-being we want for our defined whole population The priority INDICATOR we will use to determine progress towards our OUTCOME The INDICATOR BASELINE made up of the historical data, the projected forecast (if nothing is done) and showing the curve we want to turn The STORY BEHIND THE BASELINE: What we know about the factors driving the baseline. What are the causes/factors at work? What’s our best community intelligence on this issue? What are the gaps in our knowledge (our DATA DEVELOPMENT AGENDA)? What do we need to know to inform our action plan? Who are the KEY PARTNERS with a role to play in Turning the Curve? These could be public sector service providers, residents, voluntary and community organisations and businesses amongst others WHAT WOULD IT TAKE TO TURN THE CURVE? What’s our best thinking on this, our best hunches? What would work in our community? Always include at least one “No Cost/Low Cost” idea and an “Off The Wall” idea (to generate creative thinking) Whole Population Turning The Curve Report NB: ONE SIDE OF FLIPCHART PAPER ONLY! Key pointers to action

Outcome Based Accountability Managing and Improving Performance

Programme Performance Measures How much service did we deliver? How well did we deliver it? How much change/effect did we produce? What quality of change/effect did we produce? QUANTITYQUALITY EFFORT EFFECT INPUT OUTPUT Cause Effect

Drug Treatment Programme QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of clients enrolled Number of courses Number of counselling sessions % clients completing programme % counsellors trained to professional standard % clients saying they were treated well Number clients drug free At exit of programme After 12 months Number clients saying they were helped with their problems Percentage clients drug free At exit of programme After 12 months Percentage clients saying they were helped with their problems

Not All Performance Measures Are Created Equal... QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? LEAST important Also Very Important MOST important

The Matter of Control QUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? MOST control LESS control We have the least control over the most important matters PARTNERSHIPS QUANTITY

The programme, service system or project being performance managed The customers: i.e. the people whose lives are affected (for better or worse) by the actions of the programme The priority PERFORMANCE MEASURE derived in particular from the “How well” and “Better Off” (right hand quadrant) questions The PERFORMANCE MEASURE BASELINE made up of the historical data, the projected forecast (if nothing is done) and showing the curve we want to turn The STORY BEHIND THE BASELINE: What we know about the factors driving the baseline. What are the causes/factors at work? What is our understanding of what’s driving our performance? What are the gaps in our knowledge (our DATA DEVELOPMENT AGENDA)? What do we need to know to inform our action plan? Who are the KEY PARTNERS with a role to play in Turning the Curve? These could be internal departments, service users, suppliers etc. WHAT WOULD IT TAKE TO TURN THE CURVE? What’s our best thinking on this, our best hunches? What would work in our organisation? Always include at least one “No Cost/Low Cost” idea and an “Off The Wall” idea (to generate creative thinking) Performance Turning The Curve Report

Outcome Based Accountability Next Generation Commissioning

Outcome Based Commissioning Home Care Service Is anyone better off? Number of persons served No. visits per week Average length of visit % service users who say service is reliable, flexible, respectful, friendly Number service users reporting that service has enabled them to remain at home How much did we do?How well did we do it? The WHOLE POPULATION OUTCOME we’re looking to contribute to: “Increased Choice and Control” The INDICATOR we’re trying to influence (the CURVE we want to turn): Support to live independently (NI 139) (Story behind the baseline) Description of the service including the QUANTITY of service we want to buy We will measure the QUALITY of the service by these performance measures We will work together to maximise the EFFECT of the service demonstrated by these performance measures (Customer Outcomes) Service Specification (Home Care Service) Percentage service users reporting that service has enabled them to remain at home 1. You can purchase services. 2. You can purchase service quality 3. You cannot purchase customer outcomes. Instead, you can purchase a contract relationship that maximizes good customer outcomes.

Next Generation Commissioning Quantity Effect Effort 3. What we purchase in the lower quadrants are not deliverables, but rather a RELATIONSHIP where commissioner and service providers work together to maximize customer/client outcomes. WHICH MEANS BUT 2. They break down in the Is anyone better off? quadrants (because of case mix differences and perverse incentives). 1. Traditional purchasing methods work fine in the upper quadrants. Quality

The Three Essential Provisions of Next Generation Commissioning 1.The most important performance measures How much?How Well? Anyone Better Off? The three to five measures that say most about the effectiveness of the service provider’s performance* *As determined from the Five Step Method

The Three Essential Provisions of Next Generation Commissioning 2.Continuous Improvement Process Using Turning the Curve report cards based on the 7 performance accountability questions Using the same basis for management supervision across the organisation

The Three Essential Provisions of Next Generation Commissioning 3.Performance Partnership between commissioner and service provider –Periodic meetings to review progress on the three to five most importance performance measures (based on Turning the Curve reports) –Reviewing changing stories behind the baseline –Agreeing measures the commissioner can take to help improve performance as partners in facilitating improvement e.g. Technical assistance and support Brokering relationships with third parties Helping to break down barriers to progress –This does not compromise respective accountability: For commissioner’s responsibility for service provider’s performance and effective use of funds For service provider’s commitment to continuous improvement process

Other 4 Quadrant Concepts

Home Care Service QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of persons served Number of home visits Number of shopping trips Number of visits per week Average length of visit % clients saying they were treated with dignity and respect Number clients saying that service has enabled them to stay in their own home Number of clients saying they feel happy and comfortable in their own home % clients saying that service has enabled them to stay in their own home % of clients saying they feel happy and comfortable in their own home

Car Manufacture QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of units produced Tons of steel deployed Residual value of cars Warranty claims Unit cost Customer satisfaction £ Profit Margin £ Share price £ Return on Capital % Profit margin % Share price growth % Return of Capital

Private Sector Home Care Service QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of persons served Number of home visits Number of shopping trips Number of visits per week Average length of visit % clients saying they were treated with dignity and respect Number clients saying that service has enabled them to stay in their own home Number of clients saying they feel happy and comfortable in their own home % clients saying that service has enabled them to stay in their own home % of clients saying they feel happy and comfortable in their own home

Private Sector Home Care Service QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of persons served Number of home visits Number of shopping trips Number of visits per week Average length of visit % clients saying they were treated with dignity and respect % clients saying that service has enabled them to stay in their own home % of clients saying they feel happy and comfortable in their own home Number clients saying that service has enabled them to stay in their own home Number of clients saying they feel happy and comfortable in their own home

Private Sector Home Care Service QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of persons served Number of home visits Number of shopping trips Number of visits per week Average length of visit % clients saying they were treated with dignity and respect % clients saying that service has enabled them to stay in their own home % of clients saying they feel happy and comfortable in their own home Number clients saying that service has enabled them to stay in their own home Number of clients saying they feel happy and comfortable in their own home £ Profit Margin £ Share price £ Return on Capital % Profit margin % Share price growth % Return of Capital

Private Sector Home Care Service QUANTITYQUALITY EFFORT EFFECT How much did we do? How well did we do it? Is anyone better off? Number of persons served Number of home visits Number of shopping trips Number of visits per week Average length of visit % clients saying they were treated with dignity and respect % clients saying that service has enabled them to stay in their own home % of clients saying they feel happy and comfortable in their own home Number clients saying that service has enabled them to stay in their own home Number of clients saying they feel happy and comfortable in their own home £ Profit Margin £ Share price £ Return on Capital % Profit margin % Share price growth % Return of Capital

The OBA Journey – From Talk to Action DESIRED OUTCOME Choosing the INDICATORS Drawing the BASELINE (and the CURVE TO TURN) The STORY BEHIND THE BASELINE Choosing the PARTNERS Deciding WHAT WORKS The ACTION PLAN REVIEW PROCUREMENT PERFORMANCE MEASURES How Much? How Well? Better Off? (CLIENT OUTCOMES) Contributory Relationship ENDS (POPULATION ACCOUNTABILITY) MEANS (PERFORMANCE ACCOUNTABILITY)