VA has invested substantially in its External Peer Review Program (EPRP), the official data source for VA's performance management system, to monitor facilities' clinical performance. EPRP performance measures form a large part of facilities' performance evaluations, and directly affect their budgets. However, sometimes specific indicators are retired from the set used to evaluate facility performance ("performance measures"), particularly when high performance levels have been sustained. When a performance measure is retired, it is designated as a "support indicator," and no longer impacts facility budgets, though it continues to be monitored. Whether facilities sustain high performance once a performance measure becomes a support indicator or vice versa is unknown, nor is it known how long performance levels take to stabilize after a change. We hypothesized performance would increase significantly for indicators changing from support indicator to performance measure, and would decrease significantly for indicators changing the from performance measure to support indicator. We also examined the mean time to stability for measures after changing status.
Compare the nature and rate of change in VA Medical Center (VAMC) outpatient clinical performance (as measured by EPRP scores) as a function of a measure's performance evaluation status (performance measure vs. support indicator).
This research is a database review consisting of quantitative, longitudinal, retrospective analyses of clinical performance measure data from VA's EPRP. We studied seventeen measures covering five clinical areas: screening, immunization, chronic care following acute myocardial infarction (AMI), diabetes mellitus, and hypertension over varying quarters (minimum of 8) between 2000 and 2006. Data were analyzed using hierarchical linear modeling and segmented regression to test for significant differences in performance before and after a change in evaluation status from performance measure to support indicator and vice versa.
Contrary to our hypotheses, all measures either improved or remained stable over time regardless of whether they changed from performance measure to support indicator or vice versa. Of the 6 measures that changed from support indicator to performance measure, only two exhibited significant increases in slopes after the change (HbA1C <9, B_b=-.005, p=.004, B_a=.009, p<.001; colorectal cancer screening, B_b=.-01, p<.001, B_a=.02, p=.007*). Of the 11 measures that changed from performance measure to support indicator, four exhibited significant differences in slope; two exhibited positive slopes before the change followed by negative slopes (lipid profile every 2 years, Bb=.009, p<.001, Ba=.-.007, p<.001; and depression screening, B_b=.01, p<.001, B_a=.-.01, p<.001), and two exhibited the opposite pattern (diabetic foot inspections, B_b=.-.004, p=.004, B_a=.004, p=.005; and pedal pulses, B_b=.-.002, p=.19, B_a=.003, p.=.03). The remaining measures exhibited no differences in slope before versus after the change, indicating performance levels were sustained even after changing to support indicator. Finally, the amount of time required for a measure to reach stability after a change varied considerably, with some measures not reaching stability by the end of our sample period.
*B_b = Regression weight before change in status; B_a = Regression weight after change in status.
This study could indicate that facilities respond to changes in VA's performance management system with positive outcomes, irrespective of the financial impact to the facility; however, the observed effects could also be explained by the use of performance targets. Future research should determine the independent effects of performance targets and facility budget incentives, as well as the moderating effects of measure and facility characteristics.
- Hysong SJ, Khan MM, Petersen LA. Passive monitoring versus active assessment of clinical performance: impact on measured quality of care. Medical care. 2011 Oct 1; 49(10):883-90.
- Hysong SJ, Khan MK. Does Linking Performance Measures to Hospital Budgets Improve their Outpatient Clinical Performance? Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.