Journal of General Internal Medicine

, Volume 27, Issue 4, pp 405–412

Unintended Consequences of Implementing a National Performance Measurement System into Local Practice

  • Adam A. Powell
  • Katie M. White
  • Melissa R. Partin
  • Krysten Halek
  • Jon B. Christianson
  • Brian Neil
  • Sylvia J. Hysong
  • Edwin J. Zarling
  • Hanna E. Bloomfield
Original Research

DOI: 10.1007/s11606-011-1906-3

Cite this article as:
Powell, A.A., White, K.M., Partin, M.R. et al. J GEN INTERN MED (2012) 27: 405. doi:10.1007/s11606-011-1906-3

ABSTRACT

BACKGROUND

Although benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents.

OBJECTIVES

(1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients.

DESIGN, PARTICIPANTS, APPROACH

Qualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships.

RESULTS

Participants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies.

CONCLUSIONS

Facility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

KEY WORDS

health care quality assessmentquality indicatorsperformance measurementunintended consequences

Supplementary material

11606_2011_1906_MOESM1_ESM.pdf (222 kb)
ESM 1(PDF 222 KB)

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Adam A. Powell
    • 1
    • 2
  • Katie M. White
    • 3
  • Melissa R. Partin
    • 1
    • 2
  • Krysten Halek
    • 1
  • Jon B. Christianson
    • 3
  • Brian Neil
    • 4
  • Sylvia J. Hysong
    • 5
    • 6
  • Edwin J. Zarling
    • 7
  • Hanna E. Bloomfield
    • 1
    • 2
  1. 1.Core Research Investigator, Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Health Care SystemMinneapolisUSA
  2. 2.Department of MedicineUniversity of MinnesotaMinneapolisUSA
  3. 3.School of Public HealthUniversity of MinnesotaMinneapolisUSA
  4. 4.VA Midwest Health Care Network, VISN 23MinneapolisUSA
  5. 5.Houston Center for Quality of Care and Utilization StudiesMichael E. DeBakey VA Medical CenterHoustonUSA
  6. 6.Baylor College of MedicineHoustonUSA
  7. 7.North Chicago Captain James A. Lovell Federal Health Care CenterNorth ChicagoUSA