The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme

Aryankhesal, Aidin; Sheldon, Trevor; Mannion, Russell; Mahdipour, Saeade

doi:10.1177/1355819615576252

Cited by 14 publications

(19 citation statements)

References 37 publications

(42 reference statements)

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“…Information on whose performance was measured was provided for all identified P4P schemes and information on who ultimately received the payment was available for 38 out of 41 schemes. Most identified P4P schemes (76%) measured the performance of health institutions such as primary healthcare facilities [46] or hospitals [48]. However, 86% of P4P schemes in LMICs paid financial bonuses to individual providers.…”

Section: Who Is Incentivised?mentioning

confidence: 99%

“…Virtually all of the P4P schemes we identified provided financial rewards rather than penalties. Only one scheme, the Iranian National Hospital Grading Programme [48], included penalties as performance in the scheme was linked to how much hospitals can charge for patient days and hospitals with insufficient performance scores were closed.…”

Section: How Is Performance Incentivised?mentioning

confidence: 99%

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How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

Kovacs

Powell‐Jackson

Kristensen

et al. 2020

BMC Health Serv Res

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Background: Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs. Methods: We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched. Results: We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literaturewith many studies failing to report key design features. Conclusions: We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

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Section: Who Is Incentivised?mentioning

confidence: 99%

Section: How Is Performance Incentivised?mentioning

confidence: 99%

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

Kovacs

Powell‐Jackson

Kristensen

et al. 2020

BMC Health Serv Res

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“…Complacency Reduced ambition to improve caused by the perception that performance is satisfactory [ 5 , 41 , 48 ] ✓ j. Fossilization PM system excessively rigid to the point of organizational paralysis and reduced innovation (e.g., choosing not to adopt new technology or procedure so that current performance is maintained) [ 2 , 5 , 10 , 33 , 42 , 49 ] ✓ k. Systemic dysfunction Performance priorities, indicators, measurement methodologies, interpretations of data, and/or resulting actions are misaligned or contradictory across programs and hierarchical levels within an organization or between PM schemes that co-exist in the broader healthcare system [ 10 ] ✓✓ l. Resource waste Time and money are spent on PM without achieving its underlying objectives; time and money spent on unnecessary care [ 31 , 50 ] ✓ III. Breaches of Trust & Increased Toxicity of the Work Environment a. Misrepresentation Deliberate manipulation of data to appear a better performer (e.g., creative accounting, fraud, upcoding) [ 2 , 3 , 5 , 8 , 33 , 35 , 39 , 42 , 51 – 55 ] ✓ b. Gaming Deliberate manipulation of behavior to appear a better performer (e.g., cherry-picking patients, stopping the clock for wait time indicators) [ 2 , 3 , 5 , 8 , 33 , 35 , 36 , 39 – 42 , 49 ...…”

Section: Resultsmentioning

confidence: 99%

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

Evans

2022

BMC Health Serv Res

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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.

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“…The long list of requirements, which includes 37 domains with more than 1000 measures, 12 forces hospitals staff to carry out heaps of paperwork annually, not once in three-four years, and leads to their frustration. 14 Another mismatch in our comparison between the USA's hospital accreditation program and Iran's relates to the funding considerations. Owing to that hospital accreditation is a mandatory program in Iran, the governments cannot charge hospitals for application, which otherwise would seem irrational.…”

Section: View Video Summarymentioning

confidence: 99%

“…13 Against this kind of standards, hospitals may resist or game because they could not make necessary changes easily. 13,14 Moreover, we know that the effectiveness of Iranian hospital accreditation comes from its pay for performance (P4P) policy, according to which the audit scores would define hospitals' level of charges. 15 Such P4P policy conflicts with the MoHME's interests; MoHME I n a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics.…”

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confidence: 99%

Strategic Faults in Implementation of Hospital Accreditation Programs in Developing Countries: Reflections on the Iranian Experience

Aryankhesal

2016

Int J Health Policy Manag

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Establishment of hospital accreditation programs is increasingly growing across numerous developing nations. Such initiatives aim to improve quality of care. However, such establishments, mainly incentivized by successful and famous accreditation plans in developed countries, usually suffer from lack of necessary arrangements which, in turn, result in undesired consequences. Indeed, the first priority for such nations, including Iran, is not establishment of accreditation programs, yet strict licensing plans. Similarities Between Accreditation and Olympic GamesHospital accreditation programs, with a history of more than six decades in developed nations, 1 may have some similarities with the Olympic Games. Both aimed to improve the quality and outcomes, one in care and services and the other in physical abilities and records. Both work through establishment of some type of competition, the former among hospitals and the latter among athletes and nations. Indeed, the participants may first pass some basic requirements, the basic level of standards or the qualification records to be qualified for the competition. In both events, the participants are usually among the fittest ones, well-organized hospitals and the nationally selected athletes, respectively. Therefore, the expected quality of participants in the events is much higher than what is expected from the average of typical hospitals or athletes. In both, the winners are rewarded, by a gold seal, or gold medal, which brings them other achievements such as reputation and possibly financial benefits. Both events need funding, which usually come from application fees paid by applicant hospitals or the membership fees, paid by member nations. Finally, both events take place every three-four years. Such similarities are seen between most accreditation programs of developed nations and the Olympic Games. However, the story is rather different in some developing countries. 2-5Different Story in Iran and Some Developing Countries Developing countries historically suffer from a lack of effective control over hospital establishment considerations 6,7 and Iran is no exception. Such considerations may include need assessment, site selection, mapping, construction and material, wards and spaces, staffing, and equipping. Finally after the establishment, hospitals should be monitored for their clinical processes and outcomes. to prepare themselves for the accreditation. Therefore, there would be no minimum entrance requirement for accreditation. Such obligation from the government side for national accreditation was probably in order to make sure that hospitals would not miss basic requirements, as there was no other effective means that check and control the basics across hospitals. Such basic requirements could be related to space and building such as a separate entrance for emergency department (ED), minimum of 9 m 2 space per bed in any inpatient room, etc 12 or human resources that hospitals have no or less control over them.13 Against this kind of standards...

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The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme

Abstract: Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.

Cited by 14 publications

References 37 publications

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

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

Strategic Faults in Implementation of Hospital Accreditation Programs in Developing Countries: Reflections on the Iranian Experience

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