Measuring Outcomes: Lessons From the World of Public Education

Incentivizing performance in health care: a rapid review, typology and qualitative study of unintended consequences

BACKGROUND

Health systems are increasingly implementing policy-driven programs to incentivize performance using contracts, scorecards, rankings, rewards, and penalties. Studies of these "Performance Management" (PM) programs have identified unintended negative consequences. However, no single comprehensive typology of the negative and positive unintended consequences of PM in healthcare exists and most studies of unintended consequences were conducted in England or the United States. The aims of this study were: (1) To develop a comprehensive typology of unintended consequences of PM in healthcare, and (2) To describe multiple stakeholder perspectives of the unintended consequences of PM in cancer and renal care in Ontario, Canada.

METHODS

We conducted a rapid review of unintended consequences of PM in healthcare (n = 41 papers) to develop a typology of unintended consequences. We then conducted a secondary analysis of data from a qualitative study involving semi-structured interviews with 147 participants involved with or impacted by a PM system used to oversee 40 care delivery networks in Ontario, Canada. Participants included administrators and clinical leads from the networks and the government agency managing the PM system. We undertook a hybrid inductive and deductive coding approach using the typology we developed from the rapid review.

RESULTS

We present a comprehensive typology of 48 negative and positive unintended consequences of PM in healthcare, including five novel unintended consequences not previously identified or well-described in the literature. The typology is organized into two broad categories: unintended consequences on (1) organizations and providers and on (2) patients and patient care. The most common unintended consequences of PM identified in the literature were measure fixation, tunnel vision, and misrepresentation or gaming, while those most prominent in the qualitative data were administrative burden, insensitivity, reduced morale, and systemic dysfunction. We also found that unintended consequences of PM are often mutually reinforcing.

CONCLUSIONS

Our comprehensive typology provides a common language for discourse on unintended consequences and supports systematic, comparable analyses of unintended consequences across PM regimes and healthcare systems. Healthcare policymakers and managers can use the results of this study to inform the (re-)design and implementation of evidence-informed PM programs.

Ethics in contemporary health care management and medical education

RATIONALE

The health care landscape is changing: it has become the largest part of the economy and changes in public management systems will greatly affect how we practice medicine in the future. Medical education will be more important than ever to ensure patients get the best care with empathy. However, new public management systems implemented without thorough analysis might challenge medical education. An increasing number of public health care institutions provide services based on competitive market rules and express their goals in financial terms and have set financial gains as their main goal, which contradicts the fundamental nature of medical ethics and practice.

AIMS AND OBJECTIVES

To explore new public management to identify potential problems and offer possible solutions for medical education and health care institutions.

METHODS

A scoping review of the literature on public administration, hospital management, professionalism, ethics, and medical education was undertaken to map evidence on the topic and identify main concepts and knowledge gaps in the influence of management systems on the quality of medical educational practices.

RESULTS

If the accelerating changes in public management are cursorily analysed, medical education may lose the esteem in which it has long been held globally. Without precautions, the so-called new public management medical faculties will-at best-generate economic benefit, following a business model with strict quality rules, regulations, standardized products, and complex analysis and measurement systems. However, these faculties will function at a level far below the ideal of teaching institutions distinguished for their outstanding components, creativity, and ambience.

CONCLUSIONS

Patients and teaching values are not reducible to financial terms only and the acknowledgement of non-financial values is fundamental to achieve quality in health care and education. The most essential step could be selecting managers who will implement public management principles while taking into account both business requirements and medical ethics.

Clinician-Directed Performance Improvement: Moving Beyond Externally Mandated Metrics

Pay-for-performance and public reporting programs have successfully focused hospitals' attention on quality. But they have also had unintended consequences, including encouraging a narrowing of focus to mandated metrics, and their effectiveness in improving outcomes remains uncertain. Moreover, they have not successfully engaged clinicians. To offset these deficiencies, a community hospital in Santa Fe, New Mexico, developed a clinician-led quality improvement program that was parallel to its traditional quality program. Called Clinician-Directed Performance Improvement (CDPI), the program is designed to give clinicians the protected time, support, and training to select and conduct performance improvement projects. Since its implementation in September 2015, CDPI has been associated with large improvements in quality and physician engagement and has generated net savings. This article discusses the program, its results, and policy implications.

Palestinian doctors' views on patient-centered care in hospitals

BACKGROUND

Understanding the perceived importance of Patient-Centered Care (PCC) among Palestinian doctors and how the provider and other clinical characteristics may impact their views on PCC is essential to determine the extent to which PCC can be implemented. This study investigates the provision of PCC among hospital doctors in a developing and unstable country, namely, Palestine.

METHODS

This descriptive, cross-sectional research employed self-report survey among 369 Palestinian doctors working in hospitals in 2016. Respondents completed the Provider-Patient Relationship Questionnaire (PPRQ) and were asked to rate the importance of 16 PCC subjects in a context-free manner. Then they scored the existence of eight contextual attributes in their workplace.

RESULTS

Although 71.4% of the participants got training in communication, only 45% of the participants knew about PCC. 48.8% of doctors considered the "exchange of information" with patients most important PCC component. Clustering identified three groups of doctors: 32.4% of doctors reported good perceptions of PCC, 47.5% moderate; and 20.1% poor. Older, married, and specialist doctors and those familiar with PCC are more likely classified in the "good" cluster. Results revealed a significant difference between doctors' views based on their gender, experience, marital status, previous knowledge about PCC, and type of hospital in favor of males, experienced, married, familiar with PCC, and doctors in private hospital respectively. The level of job interest, nurses' cooperation, the tendency of patients to hide information, and doctor's friendly style were positively related with more perceived importance of PCC.

CONCLUSION

We identified benchmark doctors who perceive the high relative importance of PCC. Our results highlighted knowledge gaps and training weaknesses among doctors in public and private hospitals in respect to their views on PCC. Decision makers may invest in the determined contextual predictors to enhance attitudes towards PCC. This work doesn't address patients' views on PCC.