Clinical Concerns About Clinical Performance Measurement

Abstract

Performance measurement has become one of the foundations of current efforts to improve health care quality and has successfully increased compliance with practice guidelines in many settings. Despite the successes of performance measurement, many physicians remain apprehensive about its use because performance measurement "gets in the way of" delivering good care. There are several reasons clinicians might feel this way. First, performance measurement is increasingly being extended to areas that have only a small clinical benefi t and thus risk diverting attention from other more important but unmeasured aspects of care. Second, most performance measurement systems provide no priority for following guidelines likely to yield a large clinical benefi t compared with guidelines likely to yield at best a small clinical benefi t. Third, performance measures focus physicians' attention narrowly on compliance with those measures rather than more broadly on the needs of the individual patient. Because performance measures are evaluated at the level of the indicator, they may crowd out quality at the level of the patient that is equally important but that cannot be easily measured. Performance measures play an important role in improving health care quality and will undoubtedly continue to do so; however, they are only one part of the solution to improving health care quality. Good performance is not necessarily good care, and pressure to improve performance can come at the sacrifi ce of good care. In its current state, performance measurement is better suited to improving measured care than improving the care of individual patients. INTRODUCTIONP erformance measurement has become one of the foundations of current efforts to improve health care quality. The concept underlying this approach is that clinical performance will improve by setting standards for clinical processes or outcomes and measuring performance against those standards. The idea is borrowed from industrial approaches to quality improvement and has great intuitive appeal because it has the potential to link practice with evidence and standardize care.There is compelling evidence that performance measurement leads to performance improvement. For example, in 1995 the US Department of Veterans Affairs began measuring and providing feedback on performance along selected clinical indicators in screening, prevention, and treatment of common disorders. 1 Pneumococcal and infl uenza vaccination rates more than doubled as a result, and substantial improvements were made in rates of appropriate diabetes management. 2 As the successes of performance measurement have become clear, performance measures have proliferated and now cover a progressively larger portion of clinical care in many health care settings. Indeed, the potential for quality improvement is seen to be so great that measured performance is increasingly being used in the United States and elsewhere, not only to provide 160CLINIC A L PER F OR M A NCE ME A SUR EMENT quality-of-care information ...

The Double Edged Sword of Performance Measurement

“…6,[8][9][10][11][12] The critical importance of the context within which measurement results will be used has also become clear. [7][8][9][10][11] The types of unintended consequences described by Powell et al are not unique and emphasize the importance of local implementation in shaping how well broad performance measurement requirements inspire innovation and drive quality improvement. [8][9][10][11]16 Measurement and public reporting of performance results were key features of the new performance management system implemented in the Veterans Health Administration (VHA) in 1995 as part of a multi-pronged change initiative.…”

“…[7][8][9][10][11] The types of unintended consequences described by Powell et al are not unique and emphasize the importance of local implementation in shaping how well broad performance measurement requirements inspire innovation and drive quality improvement. [8][9][10][11]16 Measurement and public reporting of performance results were key features of the new performance management system implemented in the Veterans Health Administration (VHA) in 1995 as part of a multi-pronged change initiative. [2][3][4][5] This integrated change strategy led to rapid and dramatic improvements in quality of care, service satisfaction and operational efficiency, [2][3][4][5][17][18][19][20][21][22][23] prompting the Institute of Medicine, among others, to recommend that many VA quality management practices be broadly adopted in U.S. health care.…”

“…[6][7][8][9][10][11][12][13][14][15][16] Similar to any generic tool, outcomes achieved with performance measurement depend in significant part on the specific ways the tool is utilized. Prominent recurring themes in the evolving literature about health care performance measurement systems are the need for clear performance measurement objectives, assiduous attention to measure specifications (including how individual patient circumstances and preferences will be addressed), and tight linkage of measures to outcomes or clinical processes known to be connected to outcomes.…”

“…Prominent recurring themes in the evolving literature about health care performance measurement systems are the need for clear performance measurement objectives, assiduous attention to measure specifications (including how individual patient circumstances and preferences will be addressed), and tight linkage of measures to outcomes or clinical processes known to be connected to outcomes. 6,[8][9][10][11][12] The critical importance of the context within which measurement results will be used has also become clear. [7][8][9][10][11] The types of unintended consequences described by Powell et al are not unique and emphasize the importance of local implementation in shaping how well broad performance measurement requirements inspire innovation and drive quality improvement.…”

“…The changed context of performance measurement in the VA Published online January 21,2012 Health Care System is noteworthy because performance measurement drives behavior, and the specific ways measures are used will drive different behaviors. [7][8][9][10][11] Initially, VHA's performance measurement system sought to drive adoption of evidence-based clinical and management practices, encourage innovation in care processes for conditions not yet having best practices, and nurture an organizational culture of high reliability and continuous improvement. [2][3][4][5]23 A limited number of performance measures were linked to key strategic goals explicitly specified in annual negotiated performance contracts with regional Veterans Integrated Service Network (VISN) directors, who in turn implemented performance contracts with local facility managers and clinical leadership.…”