3074 — A Qualitative Study of the Unintended Effects of Performance Measurement in VHA Primary Care
Powell AA (Minneapolis VA Center for Chronic Disease Outcomes Research (CCDOR)), White KM
(University of Minnesota School of Public Health), Partin MR
(Minneapolis VA Center for Chronic Disease Outcomes Research (CCDOR)), Halek K
(Minneapolis VA Center for Chronic Disease Outcomes Research (CCDOR)), Christianson JB
(University of Minnesota School of Public Health), Hysong SJ
(Houston VA Health Services Research and Development Center of Excellence,), Neil B
(VA Midwest Health Care Network, VISN 23), Bloomfield HE
(Minneapolis VA Center for Chronic Disease Outcomes Research (CCDOR))
There may be a number of unintended consequences of current approaches to defining, measuring, and reporting quality in primary care. Yet there is little empirical research documenting the existence of such effects. This research seeks to identify and understand unintended effects of the VHA's clinical performance measurement (PM) system from the perspective of primary care staff and facility leadership.
We conducted a series of 59 in-person, individual semi-structured interviews at four VA facilities between February and July 2009. Participants included members of primary care staff (physicians, non-physician practitioners, intake nurses, clinic and service line managers) and facility leaders (facility directors, chiefs of staff, quality officers). Sites were selected to assure variability in the number of veterans served and facility scores on national VA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories, subtopics, and relationships.
Although positive “halo” effects of PM were noted, participants described a variety of negative consequences of PMs on providers, on the clinical encounter and on patients. Many negative effects were the result of local PM implementation practices. Provider effects include: frustration with measures that do not account for appropriate provider behavior, feeling chronically rushed, and increased tension between physicians and intake nurses. Effects of PM on the clinical encounter include: precedence of PM-related care over patient’s health concerns and an emphasis on quantity over quality of care. Effects on the patient include: frustration with repetition of PM-related questions, adaptive patient responses to avoid PM-related interventions, and overuse of pharmacological interventions and other forms of inappropriate care.
The volume of PMs, the emphasis placed on them, and the systems used to implement them can lead to unintended negative consequences. Further research is needed to assess the frequency of these consequences and their effects on physician-patient relationships, quality of care, and the provider and patient experience.
A better understanding is needed of the processes by which PMs are locally implemented. PMs should be developed and implemented in a manner that allows for the prioritization of care that is consistent with patient and provider values.