Katie M. White

Unintended Consequences of Implementing a National Performance Measurement System into Local Practice

ABSTRACTBACKGROUNDAlthough benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents.OBJECTIVES(1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients.DESIGN, PARTICIPANTS, APPROACHQualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships.RESULTSParticipants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies.CONCLUSIONSFacility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease.

Lay persons (“care guides”) without previous clinical experience were hired by a primary care clinic, trained for 2 weeks, and assigned to help 332 patients and their providers manage their diabetes, hypertension, and congestive heart failure. One year later, failure by these patients to meet nationally recommended guidelines was reduced by 28%, P < .001. Improvement was seen in tobacco usage, blood pressure control, pneumonia vaccination, low-density lipoprotein cholesterol levels, annual eye examinations, aspirin use, and microalbuminuria testing. Care guides served an average of 111 patients at an annual per patient cost of

More than a score: a qualitative study of ancillary benefits of performance measurement

392. Further testing of this model is warranted.

“It Has Changed My Life”: An Exploration of Caregiver Experiences in Serious Illness:

Background Prior research has examined clinical effects of performance measurement systems. To the extent that non-clinical effects have been researched, the focus has been on negative unintended consequences. Yet, these same systems may also have ancillary benefits for patients and providers—that is, benefits that extend beyond improvements on clinical measures. The purpose of this study is to identify and describe potential ancillary benefits of performance measures as perceived by primary care staff and facility leaders in a large US healthcare system. Methods In-person individual semistructured interviews were conducted with 59 primary care staff and facility leaders at four Veterans Health Administration facilities. Transcribed interviews were coded and organised into thematic categories. Results Interviewed staff observed that local performance measurement implementation practices can result in increased patient knowledge and motivation. These effects on patients can lead to improved performance scores and additional ancillary benefits. Performance measurement implementation can also directly result in ancillary benefits for the patients and providers. Patients may experience greater satisfaction with care and psychosocial benefits associated with increased provider–patient communication. Ancillary benefits of performance measurement for providers include increased pride in individual or organisational performance and greater confidence that ones practice is grounded in evidence-based medicine. Conclusions A comprehensive understanding of the effects of performance measurement systems needs to incorporate ancillary benefits as well as effects on clinical performance scores and negative unintended consequences. Although clinical performance has been the focus of most evaluations of performance measurement to date, both patient care and provider satisfaction may improve more rapidly if all three categories of effects are considered when designing and evaluating performance measurement systems.

Differential effects of professional leaders on health care teams in chronic disease management groups.

Background: Informal, unpaid caregivers shoulder much of the care burden for individuals with serious illness. As part of a project to create an innovative model of supportive care for serious illness, a series of user interviews were conducted, forming the basis for this article. Objective: To understand both individual and interpersonal aspects of caregiving for serious illness. Methods: Twelve semistructured group interviews were conducted with patients, families, and professionals as part of a larger study of late-life serious illness. Transcript data were analyzed with descriptive coding, and then coded material was analyzed to elicit major themes and subthemes. Results: A total of 73 individuals participated in group interview sessions. Using descriptive coding, quotes were assigned to first-order codes of rewards, challenges, and a category of learnings and adaptations. Subthemes of reward included gratitude, a sense of accomplishment or mastery, and closeness in personal relationships. The most oft-cited challenges included emotional and physical stresses of caregiving and feeling unprepared or unsupported in caregiving. Reflecting on their experiences, caregivers cited new ways in which they had learned to be creative, to show assertiveness and advocacy, and to create personal balance in a demanding situation. Conclusions: The experience of caregiving is a life-altering journey as individuals rise to challenges and reflect on the rewards. Caregivers described intensive caregiving, often without acknowledgment or understanding of their role from the health-care system. This invisibility created its own iatrogenic caregiving challenge. The identified themes suggest avenues of meaningful caregiver support that bear further exploration.

“This Is What Family Does”: The Family Experience of Caring for Serious Illness

Background: Leadership by health care professionals is likely to vary because of differences in the social contexts within which they are situated, socialization processes and societal expectations, education and training, and the way their professions define and operationalize key concepts such as teamwork, collaboration, and partnership. This research examines the effect of the nurse and physician leaders on interdependence and encounter preparedness in chronic disease management practice groups. Purpose: The aim of this study was to examine the effect of complementary leadership by nurses and physicians involved in jointly producing a health care service on care team functioning. Methodology: The design is a retrospective observational study based on survey data. The unit of analysis is heart failure care groups in U.S. Veterans Health Administration medical centers. Survey and administrative data were collected in 2009 from 68 Veterans Health Administration medical centers. Key variables include nurse and physician leadership, interdependence, psychological safety, coordination, and encounter preparedness. Reliability and validity of survey measures were assessed with exploratory factor analysis and Cronbach alphas. Multivariate analyses tested hypotheses. Findings: Professional leadership by nurses and physicians is related to encounter preparedness by different paths. Nurse leadership is associated with greater team interdependence, and interdependence is positively associated with respect. Physician leadership is positively associated with greater psychological safety, respect, and shared goals but is not associated with interdependence. Respect is associated with involvement in learning activities, and shared goals are associated with coordination. Coordination and involvement in learning activities are positively associated with encounter preparedness. Practice Implications: By focusing on increasing interdependence and a constructive climate, nurse and physician leaders have the opportunity to increase care coordination and involvement in learning activities.

A mixed methods study of emotional exhaustion: Energizing and depleting work within an innovative healthcare team

Background: As the demographics of caregiving in United States evolve toward multigenerational, distributed family structures, the ways in which individuals and their families experience serious illness are changing. As part of a project to create an innovative model of supportive care for serious illness, a series of user interviews were conducted, forming the basis for this article. Objective: To understand the experience of caregiving for individuals with serious illness from an intergenerational family perspective. Methods: Twelve semistructured group interviews were conducted with patients, families, and professionals. Transcript data were analyzed with descriptive coding, looking for major themes and subthemes related to family experiences. Results: Seventy-three individuals participated in group interview sessions. While both families and individuals encountered caregiving challenges, the family unit experienced care in several unique ways. It accommodated differences in temperament and readiness, managed internal conflict, and strived to emerge as a cohesive unit. Individual struggles were often magnified or, more often, ameliorated by family context. Caregiving itself formed a legacy for future generations. Finally, care was seen as bidirectional, being tendered both by the family caregivers and in turn by the patient. Conclusions: When talking about care for serious illness, individuals report both rewards and challenges, often in a family context. The family enterprise manages a loved one’s care, negotiates the health-care system, and adjusts its own internal dynamics. Integrating the family narrative provides a more balanced view of the family system that provides the day-to-day care for individuals with serious illness.

Similar perspectives on prostate cancer screening value and new guidelines across patient demographic and PSA level subgroups: A qualitative study

ABSTRACT This mixed methods study documents emotional exhaustion experiences among care team members during the development of an innovative team approach for caring for adults with serious illness. A mixed methods study design was employed to examine depleting work experiences that may produce emotional exhaustion, and energizing aspects of the work that may increase meaningfulness of work, thus reducing emotional exhaustion. The population studied included team members involved in care for adults with serious illness (n = 18). Team members were surveyed quarterly over an 18-month period using the Maslach Burnout Inventory (MBI). The MBI measures burnout, defined as the inability to continue work because of the interactional toll of the work. Analyses of MBI data show that although overall levels of burnout are low, 89% of team members reported moderate/high levels of emotional exhaustion during at least one survey period. In order to understand the kinds of work experiences that may produce or ameliorate emotional exhaustion, qualitative interviews were also conducted with team members at the end of the 18-month period. Major qualitative findings indicate that disputes within the team, environmental pressures, and standardisation of meaningful work leave team members feeling depleted. Having authentic relationships with patients, working as a team, believing in the care model, and practicing autonomy and creativity help team members to restore their emotional energy. Supports for team members’ well-being are critical for continued innovation. We conclude with recommendations for improving team members’ well-being.

ACCREDITATION AND ACCOUNTABILITY: IS THE CART BEFORE THE HORSE?

In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate‐specific antigen (PSA)‐based prostate cancer screening for all men.

Improving Chronic Disease Care by Adding Laypersons to the Primary Care Team: A Parallel Randomized Trial

As the authors of “Accountability: The Fast Lane on the Highway to Change”1 point out, public health accreditation appears to be similar to a train with a strong head of steam. The trains destination of improving population health by improving public health management is laudable. The arguments behind holding local public health departments accountable with accreditation are that it will improve population health, that marginal benefits outweigh marginal costs, and that undesirable unintended consequences can be mitigated. The causal mechanism is that accountability will result in better performance of the essential health services, which will result in improved population health.2,3 Because the accreditation standards focus on the essential services functions rather than on content, such as Healthy People 2010, the accreditation effect presumably occurs in 2 ways: (1) accreditation makes resource acquisition for population health improvement easier because it legitimizes local health departments,1 and (2) accreditation leads to better management, which improves population health. Adel Hanna of Framingham (left) and Herman Cohen of Boston (right) join a group of protestors outside of the statehouse in Boston, Massachusetts, on October 3, 1989. The noon rally was a protest against the proposed repeal of the states Universal Health Plan. Photograph by Julia Malakie. Printed with permission of AP Photo. Although anecdotal evidence of improvement suggests that accreditation can work, is it sufficient as an evidence-based approach? As the anecdote of food safety in Mississippi County, Missouri, suggests, public health is improved by implementing programs in specific content areas such as food safety. In contrast to the anecdotal evidence, the accreditation standards have an emphasis on functions rather than content; it is reasonable to argue that this emphasis may be harmful to achieving accreditation goals. While the difficulty with specifying accreditation standards in terms of content is understandable,4 has the pendulum swung too far toward functions? There are at least 6 reasons why the current approach to accreditation may be more harmful than helpful: (1) functionality is emphasized over content; (2) accreditation does not have a strong evidence base; (3) accreditation costs outweigh its benefits; (4) accreditation may have unintended consequences; (5) accreditation weakly acknowledges the contribution of related health professionals; and (6) accreditation may not fit local health department economics. (The e-note at http://www.ajph.org/cgi/eletters/99/9/1545 more fully develops these arguments.) Because of the potential harmful effects of accreditation, it may be wise to approach it in a more deliberate fashion that addresses potential difficulties. We hope this letter will help spark a broader debate about accreditation that will result in an improved accreditation process, one that has a greater promise for improving population health.