ABSTRACT
BACKGROUND
Clinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement.
OBJECTIVE
Our aim was to understand how the implementation of diabetes performance measures (PMs) influences management actions and day-to-day clinical practice.
DESIGN
This is a mixed methods study design based on quantitative administrative data to select study facilities and quantitative data from semi-structured interviews.
PARTICIPANTS
Sixty-two network-level and facility-level executives, managers, front-line providers and staff participated in the study.
APPROACH
Qualitative content analyses were guided by a team-based consensus approach using verbatim interview transcripts. A published interpretive motivation theory framework is used to describe potential contributions of local implementation strategies to unintended consequences of PMs.
KEY RESULTS
Implementation strategies used by management affect providers’ response to PMs, which in turn potentially undermines provision of high-quality patient-centered care. These include: 1) feedback reports to providers that are dissociated from a realistic capability to address performance gaps; 2) evaluative criteria set by managers that are at odds with patient-centered care; and 3) pressure created by managers’ narrow focus on gaps in PMs that is viewed as more punitive than motivating.
CONCLUSIONS
Next steps include working with VHA leaders to develop and test implementation approaches to help ensure that the next generation of PMs motivate truly patient-centered care and are clinically meaningful.
Similar content being viewed by others
REFERENCES
Kizer KW, Kirsh SR. The Double Edged Sword of Performance Measurement. J Gen Intern Med. 2012. Epub 2012/01/25.
Kerr EA, Gerzoff RB, Krein SL, Selby JV, Piette JD, Curb JD, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4):272–81. Epub 2004/08/18.
Longman P. Best Care Anywhere, 3rd Edition: Why VA Health Care Would Work Better For Everyone. 3rd ed: Berrett-Koehler Publishers; 2012. 240 p.
Francis J, Perlin JB. Improving performance through knowledge translation in the Veterans Health Administration. J Contin Educ Health Prof. 2006;26(1):63–71. Epub 2006/03/25.
Kupersmith J, Francis J, Kerr E, Krein S, Pogach L, Kolodner RM, et al. Advancing evidence-based care for diabetes: lessons from the Veterans Health Administration. Health Aff (Millwood). 2007;26(2):w156–68. Epub 2007/01/30.
Kerr EA, Fleming B. Making performance indicators work: experiences of US Veterans Health Administration. BMJ. 2007;335(7627):971–3. Epub 2007/11/10.
Sawin CT, Walder DJ, Bross DS, Pogach LM. Diabetes process and outcome measures in the Department of Veterans Affairs. Diabetes Care. 2004;27(Suppl 2):B90–4. Epub 2004/04/29.
Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP, et al. Monitoring Performance for Blood Pressure Management Among Patients With Diabetes Mellitus: Too Much of a Good Thing?Monitoring Performance for BP Management in Diabetes. Arch Intern Med. 2012:1–8. Epub 2012/05/30.
Beard AJ, Hofer TP, Downs JR, Lucatorto M, Klamerus ML, Holleman R, et al. Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment. Circ Cardiovasc Qual Outcomes. 2013;6(1):66–74. Epub 2012/12/13.
Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801–2. Epub 2012/04/12.
Pollitt C. The logics of performance management. Evaluation. 2013;19:346–63.
Tseng CL, Soroka O, Maney M, Aron DC, Pogach LM. Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med. 2014;174(2):259–68. Epub 2013/12/11.
Lester HE, Hannon KL, Campbell SM. Identifying unintended consequences of quality indicators: a qualitative study. BMJ Quality & Safety. 2011;20(12):1057–61. Epub 2011/06/23.
Powell AA, White KM, Partin MR. Halek K. Neil B, et al. Unintended Consequences of Implementing a National Performance Measurement System into Local Practice. J Gen Intern Med: Christianson JB; 2011. Epub 2011/10/14.
Kansagara D, Tuepker A, Joos S, Nicolaidis C, Skaperdas E. Hickam D. A Qualitative Study of Staff Experiences Implementing and Measuring Practice Transformation. J Gen Intern Med: Getting Performance Metrics Right; 2014. Epub 2014/02/22.
Forman J, Damschroder LJ. Qualitative Content Analysis. In: Jacoby L, Siminoff L, eds. Empirical Research for Bioethics: A Primer. Oxford, UK: Elsevier Publishing; 2008:39–62.
Mayring P. Qualitative content analysis. Forum on Qualitative Social Research. 2000;1(2).
Pritchard R, Ashwod E. Managing motivation: A manager’s guide to diagnosing and improving motivation. New York: Psychology Press; 2008. 152 p.
Pritchard RD, Weaver SJ, Ashwood E. Evidence-Based Productivity Improvement: A Practical Guide to the Productivity Measurement and Enhancement System (ProMES): Routledge; 2011.
Lunenburg FC. Expectancy theory of motivation: motivating by altering expectations. International Journal of Management, Business, and Adminstration. 2011;15(1):1–6.
van der Geer E, van Tuijl HFJM, Rutte CG. Performance management in healthcare: performance indicator development, task uncertainty, and types of performance indicators. Soc Sci Med. 2009;69(10):1523–30.
Pritchard RD, Harrell MM, DiazGranados D, Guzman MJ. The productivity measurement and enhancement system: a meta-analysis. J Appl Psychol. 2008;93(3):540–67.
Vijan S, Sussman JB, Yudkin JS, Hayward RA. Effect of Patients’ Risks and Preferences on Health Gains With Plasma Glucose Level Lowering in Type 2 Diabetes Mellitus. Intern Med: JAMA; 2014.
Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304(24):2732–7.
Mehrotra A, Sorbero ME, Damberg CL. Using the lessons of behavioral economics to design more effective pay-for-performance programs. Am J Manag Care. 2010;16(7):497–503. Epub 2010/07/22.
Van Herck P, Annemans L, De Smedt D, Remmen R, Sermeus W. Pay-for-performance step-by-step: introduction to the MIMIQ model. Health Policy. 2011;102(1):8–17. Epub 2010/11/03.
Fehr E, Falk A. Psychological foundations of incentives. European Economic Review. 2002;46:687–724.
Cassel CK, Jain SH. Assessing individual physician performance: does measurement suppress motivation? JAMA. 2012;307(24):2595–6. Epub 2012/06/28.
Nudurupati SS, Bititci US, Kumar V, Chan FTS. State of the art literature review on performance measurement. Computers & Industrial Engineering. 2011;60(2):279–90.
Friedberg MW, Damberg CL. A five-point checklist to help performance reports incentivize improvement and effectively guide patients. Health Aff (Millwood). 2012;31(3):612–8. Epub 2012/03/07.
Bourne M, Neely A, Mills J, Platts K. Why some performance measurement initiatives fail: lessons from the change management literature. Int J Bus Perform Manag. 2003;5(2):245–69.
Witter S, Toonen J, Meessen B, Kagubare J, Fritsche G, Vaughan K. Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation. BMC Health Services Research. 2013;13(1):367. Epub 2013/10/01.
Panzer RJ, Gitomer RS, Greene WH, Webster PR, Landry KR, Riccobono CA. Increasing demands for quality measurement. JAMA. 2013;310(18):1971–80. Epub 2013/11/14.
McEvoy V. Why ’Metrics’ Overload Is Bad Medicine; Doctors must focus on lists and box-checking rather than patients. Wall Street Journal. 2014 February 12, 2014;Sect. Opinion.
Doran T, Kontopantelis E, Reeves D, Sutton M, Ryan AM. Setting performance targets in pay for performance programmes: what can we learn from QOF? BMJ. 2014;348:g1595. Epub 2014/03/07.
Powell AA, White KM, Partin MR, Halek K, Hysong SJ, Zarling E, et al. More than a score: a qualitative study of ancillary benefits of performance measurement. BMJ quality & safety. 2014. Epub 2014/02/14.
Acknowledgements
The authors would like to thank the clinical leaders, physicians, and staff who participated in this study. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Contributors
Thanks also to Rob Holleman for his analysis support and Mandi Klamerus for her assistance in editing this manuscript.
Funders
This work was undertaken as part of a grant funded by the Department of Veteran Affairs, Quality Enhancement Research Initiative (QUERI; Grant RRP 11–420). Ann-Marie Rosland is a VA HSR&D Career Development Awardee.
Prior Presentations
Laura Damschroder, Claire Robinson, Joseph Francis, Tim Hofer, Doug Bentley, Sarah Krein, Ann-Marie Rosland, Eve Kerr. Bringing Performance Measurement into the Age of Patient-centered Care. AcademyHealth 2014 Annual Research Meeting (ARM). Poster Presentation. San Diego, CA. June 8, 2014.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
ESM 1
(DOCX 23 kb)
Rights and permissions
About this article
Cite this article
Damschroder, L.J., Robinson, C.H., Francis, J. et al. Effects of Performance Measure Implementation on Clinical Manager and Provider Motivation. J GEN INTERN MED 29 (Suppl 4), 877–884 (2014). https://doi.org/10.1007/s11606-014-3020-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-014-3020-9