Finding the Right Balance Between Measurement and Improvement
In the April 5, 2016 issue of The Journal of the American Medical Association (JAMA), Don Berwick, MD offers an insightful interpretation of the health care landscape.1 He describes three eras of medicine and healthcare. Era 1 is the ascendancy of the profession, anchored in beneficence and professionalism. During this time, physicians were trusted to do the right thing for their patients.
Berwick writes, “The idealism of era 1 was shaken when researchers examining the system of care found problems, such as enormous unexplained variation in practice, …injustice related to race and social class, and profiteering. These findings made a pure reliance on trusted professionalism seem naive.”
The result was era 2 which focuses on accountability, scrutiny and measurement to basically protect patients from their doctors. Berwick continues, “The machinery for era 2 is the manipulation of contingencies: rewards, punishments, incentives and markets…..Champions of era 2 invest in more and more ravenous inspection and control.” The consequence is the creation of a measurement industry that diverts large sums of dollars away from care to analyzing measures; some of which are meaningful but many of which are meaningless. Further, many of these measures assume that health professionals know what is best for each patient rather than measuring the team’s success in reaching mutually agreed upon goals of care. The result has been a remarkable level of burnout in primary care and an overall sense of being continually judged by an ever increasing set of stake-holders.
Era 3 is the future where Berwick suggests we measure only what matters and use the information for learning; not judgement, incentives or punishment. He suggests stopping complex individual incentives, shifting the business strategy from revenue to quality, regularly using improvement science (process control charts, PDSA cycling), insuring complete transparency, conducting quality improvement interactions respectfully, listening carefully to what patients want and rejecting greed.
EagleDream Health staff has over 15 years’ experience in engaging physicians to address unwarranted variation in care, focusing especially in low value services. During that time, we have come to the same conclusions as Dr. Berwick.
We have argued against focusing on external motivation such as offering major financial incentives. Instead, we encourage focusing attention more on practitioner’s internal motivation to want to do what is appropriate for their patients in the context of actionable accurate peer comparison data. Given accurate, clinically meaningful data, a medically sound context in which to place it, and respectful sharing of that data, we continually find significant reductions in the use of low value services2-4. Our programs are anchored in a model of behavior change called self-determination theory which basically comes down to organizations promoting a culture where practice teams are 1) only asked to focus on activities they believe are possible to achieve, 2) given the autonomy to solve those problems in ways they discover and create, and 3) asked to participate with others in accomplishing goals they believe are meaningful in contributing to the greater good.
Our experience is that given this approach, which is all to uncommon, practitioners rise to the occasion, engage in conversations with peers about indications