Health'System'Performance'Measurement'in'a' Circumpolar'Context:'Selecting'Performance'Indicators'for' Maternity'Care' ' by' ' Rebecca'Rich' A'thesis'submitted'in'conformity'with'the'requirements' for'the'degree'of'Master'of'Science' Institute'of'Health'Policy,'Management,'and'Evaluation' University'of'Toronto' ©'Copyright'by'Rebecca'Rich'2016' Health'System'Performance'Measurement'in'a'Circumpolar' Context:'Selecting'Performance'Indicators'for'Maternity'Care' Rebecca Rich Master of Science Institute of Health Policy, Management, and Evaluation University of Toronto 2016 ' Abstract' Performance measurement is a necessary component of a transparent health system. In circumpolar regions, indicators that align with national strategies may fail to address priorities of northern, remote, or Indigenous populations. The objective of this study was to select contextually appropriate performance indicators for maternity care in circumpolar regions. A scoping review of the academic and grey literatures generated a working list of indicators. Fourteen circumpolar maternity care experts then participated in a two-round modified Delphi consensus process. Eleven indicators met criteria for importance, circumpolar relevance, validity, and reliability. Twenty-nine additional indicators were identified for further consideration. This study demonstrated that while most circumpolar maternity care systems engage in performance reporting, current indicators do not always reflect local priorities. This study was effective in identifying contextually appropriate indicators. Future work should ensure that circumpolar performance indicators capture issues related to social determinants of health, travel for care, and cultural competency. ii ' ' ' ' ' There are no technical solutions to problems of interpretation ~ Freeman 2002 (p.133)(1) iii AcKnowledgments' I would like to extend my sincerest appreciation to my supervisor, Dr. Kellie Murphy. I cannot thank you enough for your support, encouragement, and guidance. Your willingness to take on the supervision of this project is a testament to your kindness, broad research skills, open- mindedness, and commitment to resident education. You are truly a remarkable physician and role model. I am also tremendously grateful for the guidance and support of my other committee members, Dr. Jeremy Veillard and Ms. Susan Chatwood. Jeremy, I didn’t know the first thing about performance measurement when I entered your classroom. Your guidance in developing my research ideas and acquiring the necessary background knowledge has been invaluable. Susan, this project would not have been possible without your deep and nuanced understanding of the circumpolar context, your creativity, and your extensive research network. Thank you so much for providing me with a warm, inspiring, responsive and dog-friendly home at ICHR. I would also like to acknowledge other contributors to this project: Thomsen D’Hont for assisting with the often thankless tasks of abstract screening and data collection. Thank you for improving my skiing, introducing me to fat biking, and being all around excellent ambassador for Yellowknife. You are going to make a stellar physician. Janice Linton, thank you for sharing your knowledge of the Aboriginal health literature and for your superb searching. Be’sha Blondin, I am so honored to have been able to work with you. Mahsi for all of your time and wisdom. Finally, to the incredible clinicians, researchers and advocates who live and work in the North and were generous enough to participate in this study, I am grateful to have had a chance to work with and learn from you. Your dedication to improving the health and wellness of northerners is inspiring. I would also like to thank Dr. Donna Steele (residency program director) and Dr. John Kingdom (department chair) from the University of Toronto Department of Obstetrics and Gynecology for their support, and the opportunity to participate in the Clinician Investigator Program. Finally, to my family and friends, your support means the world. Hart Stadnick, I am so grateful to have you in my life. Thank you for helping to keep my ‘Amy’ in check and for helping with Appendix 6. I would like to acknowledge the following scholarship/funding programs: The Ontario Ministry of Health – Clinician Investigator Program salary support funding; The Canadian Foundation for Women’s Health (CFWH) Dawn Walker Award; The Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) Patient Engagement grant. iv Table'of'Contents' Acknowledgments .......................................................................................................................... iv! Table of Contents .............................................................................................................................v! List of Tables ................................................................................................................................. ix! List of Abbreviations .......................................................................................................................x! List of Figures ............................................................................................................................... xii! List of Appendices ....................................................................................................................... xiii! Chapter 1 Background .....................................................................................................................1! 1! Background .................................................................................................................................1! 1.1! Introduction ..........................................................................................................................1! 1.2! Positioning the researcher ....................................................................................................2! 1.3! Theoretical frameworks .......................................................................................................2! 1.4! Circumpolar context .............................................................................................................3! 1.4.1! Circumpolar geography ...........................................................................................3! 1.4.2! Circumpolar peoples ................................................................................................8! 1.4.3! Maternity care in northern Canada ........................................................................11! 1.5! Health system performance measurement .........................................................................13! 1.5.1! The purpose of measuring health system performance ..........................................13! 1.5.2! Challenges and limitations of performance measurement .....................................15! 1.5.3! Performance indicator selection & development ...................................................16! 1.5.4! Performance measurement frameworks .................................................................18! 1.5.5! Health system performance and Indigenous peoples .............................................23! 1.6! Objectives & research questions ........................................................................................24! 1.7! Ethics ..................................................................................................................................25! 1.8! Map of the thesis ................................................................................................................26! v Chapter 2 Scoping Review .............................................................................................................27! 2! Scoping Review ........................................................................................................................27! 2.1! Abstract ..............................................................................................................................27! 2.2! Introduction ........................................................................................................................28! 2.3! Methods..............................................................................................................................29! 2.3.1! Setting and population ...........................................................................................29! 2.3.2! Search strategy .......................................................................................................30! 2.3.3! Article selection .....................................................................................................31! 2.3.4! Data extraction .......................................................................................................34! 2.4! Results ................................................................................................................................34! 2.4.1! Included publications .............................................................................................34! 2.4.2! Available performance measurement frameworks ................................................38! 2.4.3! Available performance indicators ..........................................................................39! 2.5! Discussion ..........................................................................................................................42! 2.6!