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Performance Assessment Tool for Estonian hospitals

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Agris Koppel, Ain Aaviksoo
Health Policy Issues: 
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja ja nein nein nein nein nein
Featured in half-yearly report: G-politik in Industrieländern 10


In 2005 a network of hospitals for implementing WHO Europe's Performance Assessment Tool for quality improvement in Hospitals (PATH) was created in Estonia. A first pilot project on the choice of quality indicators was conducted in 2006 and after that Estonian hospitals are ready to participate in the international network of the PATH project. The PATH project in Estonia has been mediated by the Estonian Health Insurance Fund.

Purpose of health policy or idea

The main idea behind introducing the Performance Assessment Tool for Hospitals (PATH) is to make hospital managers conscious about the need for performance monitoring in hospitals. Performance and quality measuring has not been a high priority during last health reforms in Estonia, when main efforts were put into economic development and optimising health care provision. However there has been a number of attempts to improve quality at the provider level. Over the past years a framework and a number of indicators for hospital performance management has been developed, but not implemented (in 2003). In addition a quality handbook has been developed and most of the hospitals are implementing patient satisfaction surveys and other means to measure parts of the quality.

PATH is a methodology which has been developed by the World Health Organisation's European Regional Office since 2003. The collaboration between WHO, the Estonian Health Insurance Fund and hospitals on the PATH project is one of the areas biennial collaboration over last years. At the regional level data is gathered and analysed from more than 200 hospitals in 10 European countries. In 2004 the first pilot project started in 6 European and 2 non-European countries. Estonia was invited to join the pilot project in 2005. At present there are 4 central hospitals and 2 regional hospitals involved into the PATH project in Estonia.

Main points

Main objectives

The main objective of introducing PATH in Estonia is to develop a commonly accepted and suitable performance self-assessment instrument for Estonian hospitals. The  main characteristics of the monitoring tool are described by WHO as following:

  • indicators are understood for physicians and administrators
  • monitoring and data gathering means no surcharge for hospitals as those data could be used routinely in hospital management
  • data should be comparable to other hospitals in country and abroad
  • information from data analysis should give the input to the management decisions
  • indicators are evidence based

The main expected result of the project will be a performance monitoring tool (set of indicators) that is usable for routine self-assessment of hospital activities. In the long run this can provide the basis for benchmarking and quality improvement at hospital level. However of most importance is the development of a performance monitoring culture in Estonian hospitals. 

Type of incentives

There is no direct financial incentives connected to the participation in the pilot project of developing PATH for Estonian hospitals, but the main outcomes of the project are expected to be an increased performance and quality of hospital services.

The main incentive for hospitals in Estonia is possibility to compare their quality and performance with hospitals from other countries.

Groups affected

Hospitals, Patients


Characteristics of this policy

Innovationsgrad traditionell recht innovativ innovativ
Kontroversität unumstritten kaum umstritten kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering recht hoch sehr hoch
Übertragbarkeit sehr systemabhängig recht systemneutral systemneutral

The WHO PATH project has been developed by the WHO. Even though the indicators used are well known, the aspect of voluntary international participation of hospitals in the network is rather innovative. Implementing he PATH methodology in hospitals should be a universal process and does not require any surcharge efforts for data collection and analysis. The possibility for benchmarking and knowledge transfer creates a rather consensual platform on PATH implementation and has a fundamental impact on hospital management processes. Although PATH is meant to be used only for internal purposes it is expected that quality improvement in health services and hospital management will around the mid-term also be perceived by the public.

Political and economic background

 The topic of health service quality has been discussed more generally during the last decade and there is a special governmental directive regarding quality assurance. The quality of health services has been rising as a result of increasing financial resources, but monitoring of hospital activities and management of hospitals has not been based on commonly accepted performance indicators. During health care reforms in Estonia many foreign experts have stated the need for monitoring and quality assurance in the health system. This has been seen as part of the overall quality improvement, there have been conducted a number of seminars covering the topic, the topic has been discussed in hospital boards, and a few pilots have been performed.

In the last years treatment guidelines for most specialities have been developed, which have been outsourced by the Estonian Health Insurance Fund (EHIF) and which could be used by hospitals as part of their quality assurance. The EHIF has also developed the external quality evaluation practice through clinical audits of health services provision in special areas. The PATH project is supposed to be general benchmarking tool.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja ja nein nein nein nein nein

Origins of health policy idea

 The WHO Country Office in Estonia conducted a seminar on performance measurement at the provider level and introduced the PATH methodology to EHIF and hospital managers. The detailed discussion on the PATH methodology was held with EHIF as the organisation which has close contacts and has most of the activity data from all health providers in Estonia. However, for the PATH project additional information was needed. EHIF has been the binding body for setting up the network of Estonian hospitals as the organisation is experienced in having active dialogue with providers.

 At the first stage in 2005, the 4 central and 2 regional hospitals and EHIF created a Task Force on introducing themselves to the basis of PATH with the aim to join the international PATH project in 2006. Monthly meetings have been conducted over two years to discuss performance management, solve practical issues and develop capacities. During 2005 and 2006 some indicators were used for pilot performance assessment in Estonia. In 2006 the set of indicators had already  been internationally agreed on and Estonian hospitals were willing to participate by sending data to the project to receive further standardized feedback.

Initiators of idea/main actors

  • Leistungserbringer: Only regional and central hospitals involved
  • Kostenträger
  • Internationale Organisationen

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Local level - On the local level there are 6 hospitals participating in the project in Estonia,
Within institution - 2 regional and 4 central hospitals are involved and
Pilot project - the international pilot project was introduced in 2004 in 8 countries, locally in 2005 in 6 hospitals

Stakeholder positions

The objective of the project is to support hospitals in assessing their performance, analysing their own results, and translating them into actions for quality improvement (from WHO webpage). The policy is oriented to design the performance assessment tool only for internal use and on a voluntary basis. However the added value in Estonia has been that all the regional and central level hospitals have been actively participating in the network.

Therefore all hospitals are participating in the project on their own will and they are supporting the developments as far as these are directed to improve their ability to collect, analyse and use the information of hospital activities for better management. There is some uncertainity within hospitals' relationships with EHIF as they are concerned that EHIF could use the collected data for their purposes. However these concerns are not justified as the data is collected and sent directly to the project coordination centres at WHO.

The EHIF has been involved into the project as promoter of the PATH development in Estonia. EHIF has been the leading public body in health care for developing the electronic data collection, analysis and feedback of information and it has a lot of experience of negotiations with hospitals. Therefore, EHIF has been supporting the introduction of the PATH methodology in Estonian hospitals on behalf of  the insured population, who are interested in quality improvement and sustainable development of hospital services, but has also been mediating possible conflicts between different hospitals.

Other stakeholders, such as the Ministry of Social Affairs, the Estonian Hospital Association etc, have been informed about the PATH project, but they do not participate actively in the network. But evidently other parties also expect improvements in the quality of health services and hospital management practices.

Actors and positions

Description of actors and their positions
Hospital managerssehr unterstützendunterstützend stark dagegen
Estonian Health Insurance Fundsehr unterstützendsehr unterstützend stark dagegen
Internationale Organisationen
WHOsehr unterstützendsehr unterstützend stark dagegen

Influences in policy making and legislation

Since the PATH project is based on voluntary participation and there is only internal use of information at the hospital level, there is no direct influences on the legislative process. However if hospitals wish to share their performance results this would have a policy implication. There is the regulation of Ministry of Social Affairs of health care services quality and in general the current project aims are in accordance to these requirements.

Legislative outcome


Actors and influence

Description of actors and their influence

Hospital managerssehr großgroß kein
Estonian Health Insurance Fundsehr großgroß kein
Internationale Organisationen
WHOsehr großgroß kein
Estonian Health Insurance Fund, WHOHospital managers

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

 The pilot project for using the PATH in hospitals was introduced in 2004 by WHO in 6 European and 2 non-European countries. In 2005 the results were analysed and since 2006 the network of hospitals using PATH has been established. Further data collection is ongoing in 2007 in order to have standardised feedback to providers in early 2008. To facilitate knowledge transfer across the country the international meetings have been convened.

In Estonia the network of regional and central hospitals was established in 2005 as these hospitals are comparable in size and volume of services. First indicators of PATH were piloted in Estonia in 2006 and therefore Estonian hospitals have agreed to collect and send the data to the international PATH project since 2007.

As the PATH project is based on voluntary participation and all information should be used only for internal purposes, no outside motivation is used for hospital involvement. The benefit of using PATH in hospital is based on the idea that the information can be gathered and used on a routine basis for improving the health services and decisions connected to hospital management.

Monitoring and evaluation

The main motivation for hospitals to participate was the agreement that the PATH methodology would be used regularly in a long-term run. They try to establish a network for continuous monitoring, benchmarking and collaboration on quality improvement between hospitals.

The monitoring and evaluation of the PATH methodology implementation in hospitals is based on the simple idea that hospitals are ready to voluntarily collect and share information with other network partners.

Review mechanisms

keine Angaben

Dimensions of evaluation

Ergebnis, Prozess

Results of evaluation

There is no evaluation on the PATH implementation process done in Estonia and also non on the international level due to the early stage. But the growing interest for participation in the PATH project is a positive sign for the quality and utility of implementing the PATH methodology in hospitals.

Expected outcome

The introduction of WHO's international PATH project in Estonia has been a successful process and most of the conflicts between hospitals have been mediated by the EHIF. Some controversy between participating hospitals and EHIF about the role of the latter has occured at the first stages of project. But as participation in the project is voluntary,  hospital managers have overcome their mistrust against EHIF's role in the project. All information gathered by the hospitals is only for internal use and therefore it is expected that hospitals who manage to implement the PATH methodology in their monitoring systems will gain most regarding improved quality and management decision processes.

Beside financial efficiency and optimisation of services, PATH implementation in Estonia is expected to bring hospital managers' attention to quality management,  which means that this process can be seen as a step to improved population health.

Impact of this policy

Qualität kaum Einfluss starker Einfluss starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering high sehr hoch

PATH is based on set of core indicators which are evidence-based and let hospital managers improve their decision making processes about improving the health services provision (including the quality of services).


Sources of Information

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo. "Performance Assessment Tool for Estonian hospitals". Health Policy Monitor, October 2007. Available at