Characteristics of health indicators


Lack N, Bréart G, Bloch VVH, Gissler M, Göpel W, Haumont D, Hummler H, Loureiro B, Vavouraki E, Zeitlin J

Target group

Infants and parents

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Quality and health indicators in neonatal healthcare comply with published standards and help to increase comparability.


Quality and health indicators help to measure and compare quality of care and health services with the purpose of monitoring progress towards defined goals. They are essential for informing policy, managing the healthcare system, enhancing our understanding of the broader determinants of health, as well as identifying gaps in health status and outcomes of specific populations. Furthermore, indicators provide concise information of health situation and trends. While there are countless indicators that could be used, the challenge is to identify those which best reflect the needs and those which are the most relevant to document quality of neonatal care. (1–4) Especially for high-risk newborn infants long-term follow-up is essential for evaluating outcomes (5) and this longitudinal perspective must be considered when identifying indicators to assess standards of care.

Countries can use indicators for monitoring in accordance with their own health priorities and capacity, as they allow comparisons between quality of care and health services and assessment of the impact of particular factors on the quality of national health services. (6)

Indicators are based on standards of care. The demand for valid and reliable data to ensure informed decision making implies that indicators are constructed according to standard methods. To ensure that reliable and valid indicators are used, they must be designed, defined, and implemented rigorously. Availability and quality of indicators can be improved by combining existing data sources from vital statistics, hospital data, and other registers. (7,8) A comprehensive list of accepted standard methods exists and may be drawn upon. (9–14)


  • Consistent reporting in health outcomes and quality of care (consensus)
  • Increased comparability of quality of healthcare over time and different locations (consensus)
  • Easily understandable indicators of healthcare (consensus)
  • Facilitated judgements and setting of priorities (consensus)
  • Facilitated measurement and tracking clinical performance and outcomes (consensus)
  • Monitoring and evaluation of healthcare quality (consensus)
  • Improved quality of healthcare (consensus)
  • Increased availability of trend analyses (consensus)
  • Facilitated collaboration across sectors (consensus)
  • Facilitated benchmark reporting (consensus)
  • Worldwide comparability of healthcare indicators (consensus)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed about collection of personal data where not automatically protected by local legislation. B (High quality) Audit report, parent feedback
2. Patient reported outcome measures are considered and carefully defined in the development of healthcare indicators. (15) A (Low quality) Audit report, parent feedback
3. Parents are involved in the development of healthcare indicators. (10,11,16) A (Low quality) Parent feedback
For healthcare professionals    
4. Information on the importance and appropriateness of healthcare indicators is included within the curricula. B (Low quality) Training documentation
For neonatal unit and hospital    
5. Healthcare indicators are used for reporting. B (Moderate quality) Audit report
For health service    
6. A national policy statement on the use of valid and reliable healthcare indicators for reporting is available and regularly updated. B (High quality) Policy statement
7. Healthcare indicators need to be selected according to determined and common criteria. (1,8,10,14) A (Moderate quality) Audit report
8. Standardised reporting at national and international level is carried out (12,13) and results in appropriate action. (9,10) A (Moderate quality)
B (Moderate quality)
Audit report
9. Routine data is available for research to ensure development of better indicators and the analysis of data for improving practice and policy. B (Moderate quality) Clinical records, guideline
10. In recordings of births and deaths, international recommendations are adhered to. (17) B (Moderate quality) Guideline

Where to go

Further development Grading of evidence
For parents and family  
For healthcare professionals  
For neonatal unit and hospital  
For health service  
  • Harmonise international healthcare indicators.
B (High quality)
  • Develop novel healthcare indicators, e.g. quality of life, parent satisfaction, family-centred care, and well-being.
B (High quality)
  • Contribute to higher quality global databases of health results.
B (High quality)

Getting started

Initial steps
For parents and family
  • Define areas of interest for which data are needed.
For healthcare professionals
  • Define areas of interest for which data are needed.
For neonatal unit and hospital
  • Analyse patient outcome and define a minimum dataset for indicators of quality measures.
For health service
  • Implement information of the importance of healthcare indicators in the curriculum.
  • Develop and implement a policy statement on the use of valid and reliable healthcare indicators for reporting.
  • Identify and define a core set of indicators and measurement needs for women’s and infants’ health.
  1. Consensus Conference on Health Indicators, Statistics Canada, Canadian Institute for Health Information. The Health Indicators Project: report from the third Consensus Conference on Health Indicators. [Internet]. Ottawa: Canadian Institute for Health Information; 2009 [cited 2017 Sep 11]. Available from:
  2. World Health Organization. 2015 Global Reference List of 100 Core Health Indicators. 2015.
  3. World Health Organization. Accountability for Women’s and Children’s Health. Recommendation 2: Health indicator [Internet]. WHO. [cited 2017 Oct 26]. Available from:
  4. European Statistical System Committee. EUROPEAN STATISTICS CODE OF PRACTICE. For the National Statistical Authorities and Eurostat (EU statistical authority) [Internet]. 2017 [cited 2018 Jul 10]. Available from:
  5. Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet Lond Engl. 2008 Jan 19;371(9608):261–9.
  6. Organisation for Economic Co-operation and Development (OECD). Data for Measuring Health Care Quality and Outcomes [Internet]. [cited 2018 Jul 10]. Available from:
  7. Delnord M, Szamotulska K, Hindori-Mohangoo AD, Blondel B, Macfarlane AJ, Dattani N, et al. Linking databases on perinatal health: a review of the literature and current practices in Europe. Eur J Public Health. 2016 Jun;26(3):422–30.
  8. Zimbeck M, Mohangoo A, Zeitlin J. The European perinatal health report: Delivering comparable data for examining differences in maternal and infant health. Eur J Obstet Gynecol Reprod Biol. 2009 Oct;146(2):149–51.
  9. Geraedts M, Selbmann H-K, Ollenschlaeger G. Critical appraisal of clinical performance measures in Germany. Int J Qual Health Care J Int Soc Qual Health Care. 2003 Feb;15(1):79–85.
  10. Mainz J. Developing evidence-based clinical indicators: a state of the art methods primer. Int J Qual Health Care J Int Soc Qual Health Care. 2003 Dec;15 Suppl 1:i5-11.
  11. National Quality Measures Clearinghouse (NQMC). Using Measures [Internet]. Available from:
  12. Arah OA, Westert GP, Hurst J, Klazinga NS. A conceptual framework for the OECD Health Care Quality Indicators Project. Int J Qual Health Care J Int Soc Qual Health Care. 2006 Sep;18 Suppl 1:5–13.
  13. Mattke S, Epstein AM, Leatherman S. The OECD Health Care Quality Indicators Project: history and background. Int J Qual Health Care J Int Soc Qual Health Care. 2006 Sep;18 Suppl 1:1–4.
  14. Doran G. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev. 1981;70(11):35–6.
  15. Weldring T, Smith SMS. Patient-Reported Outcomes (PROs) and Patient-Reported Outcome Measures (PROMs). Health Serv Insights. 2013 Aug 4;6:61–8.
  16. Kötter T, Schaefer FA, Scherer M, Blozik E. Involving patients in quality indicator development – a systematic review. Patient Prefer Adherence. 2013 Mar 27;7:259–68.
  17. Mohangoo AD, Blondel B, Gissler M, Velebil P, Macfarlane A, Zeitlin J, et al. International Comparisons of Fetal and Neonatal Mortality Rates in High-Income Countries: Should Exclusion Thresholds Be Based on Birth Weight or Gestational Age? Wright L, editor. PLoS ONE. 2013 May 20;8(5):e64869.

November 2018 / 1st edition / next revision: 2028 Recommended citation

EFCNI, Lack N, Bréart G et al., European Standards of Care for Newborn Health: Characteristics of health indicators. 2018.

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