Chasing the Promise of Performance: A Case Study Exploring the Implementation of a Standards-Based Accountability Policy Intervention in the Ontario Public Health System

OBJECTIVE: This research project examines the development and implementation of Ontario’s system of public health accountability and performance management through two cross-cutting themes: control and results. This research project represents one of the first attempts to bridge the fields of public administration and new public management, policy implementation, and quality improvement in an examination of accountability and performance improvement in the public health sector. METHODS: This study involved semi-structured, in-depth interviews with informants in three public health units (n=20) and with representatives from the Ministry of Health and Long-Term Care (MOHLTC) (n=4). A web-survey of public health managers (n=53) was also carried out. Document review supplemented these two main data sources. Qualitative data were coded and analyzed using Atlas.ti 6.2 and quantitative data were exported to SPSS for descriptive and bivariate analysis. FINDINGS: Control, emphasizing compliance-based accountability, top-down implementation, and performance measurement for quality assurance had a dominant presence in policy development and implementation that negatively affected the pursuit of results (i.e. emphasis on performance, bottom-up implementation, and measurement for quality improvement). Pre-existing accountability structures challenged efforts to establish performance improvement as a key consideration. Despite evidence of consultation with the field, the MOHLTC’s exercise of final decision rights in policy development reinforced limitations on managerial discretion. Top-down implementation featured considerable conflict over the means of policy achievement (i.e. measurement components, resources, timelines, and some service protocols). Conflict was often met with concern amongst local public health informants over the prospective utility of performance information for improving population health outcomes. The province’s adoption of continuous quality improvement, presenting both barriers and facilitators, also confounded the prospect of substantial systemic improvement. CONCLUSION: This empirical examination of a nascent and evolving system of public health accountability and performance management strongly emphasized a control orientation with some elements supporting results. The bridging of these three fields and the application of these two cross-cutting themes provided a useful basis on which to understand public health accountability and performance improvement in Ontario. This approach merits use in future examinations of this or similar systems, particularly where performance output and outcome information is available.Ph.D