3100 — "Beyond our control": How organizational context impacts performance measurement

Harrod M, VA Ann Arbor Health Care System, Center for Clinical Management Research, Ann Arbor, MI; Forman J, VA Ann Arbor Health Care System, Center for Clinical Management Research, Ann Arbor, MI; Robinson CH, VA Ann Arbor Health Care System, Center for Clinical Management Research, Ann Arbor, MI; Weston LE, VA Ann Arbor Health Care System, Center for Clinical Management Research, Ann Arbor, MI; Tremblay A, VA Ann Arbor Health Care System, Center for Clinical Management Research and Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Greenstone CL, VA Ann Arbor Health Care System, Center for Clinical Management Research and Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Kerr EA, VA Ann Arbor Health Care System, Center for Clinical Management Research and Department of Internal Medicine, University of Michigan, Ann Arbor, MI;

Objectives:
The Patient-Aligned Care Team (PACT) model required rearranging primary care staff into "teamlets" necessitating them to work in teams and change clinic processes to meet PACT performance measures. These measures (i.e., same-day access and continuity) have been implemented as indicators of PACT success. However, most of the focus of implementing PACT has centered on primary care with little attention paid to the broader system of care. Therefore, the objective of this study was to identify factors external to primary care that may impact PACT performance measures.

Methods:
This study examined how one large primary care clinic implemented a coaching model to help newly formed teamlets develop processes to improve access and continuity. Nine of 20 teamlets' coaching sessions were longitudinally observed. Observations were followed by semi-structured interviews with observed teamlet members (N = 13). Data were analyzed using an inductive content analysis approach.

Results:
Many primary care providers (PCPs) felt the measures did not accurately reflect access and continuity because they focused on the PCP, and did not reflect efforts made to incorporate team members in providing care. Additionally, PCPs observed that access was not always within their control. Several factors external to primary care affected their ability to meet goals including a locally-centralized call center with variable understanding of PACT, inpatient physicians discharging patients with instructions to "follow-up with primary care in 7-10 days," and questions about when responsibility for care shifted back to primary care after a hospital admission by a specialist. While PACT performance measures were instituted to hold primary care accountable for improving access, when used as quality improvement tools, they highlighted where organizational processes were not aligned.

Implications:
Improving performance measures requires an understanding of the entire practice context. In our study, measurement results that fell short of goals reflected a misalignment of organizational processes. It is important to develop processes to meet PACT goals across the organization rather individual metrics.

Impacts:
A better understanding of what is being measured, how measures reflect patient-centered care, unintended consequences of measures, and how to align organizational goals is needed so that performance reflects true quality of care and patient-centeredness.