Of Measures and Men

News about the Veterans Affairs (VA) scandal this summer coincided with my being in the midst of reading Daniel Pink’s ‘Drive: The Surprising Truth About What Motivates Us’. Pink’s chapter on unethical behavior seemed uncannily relevant as it described how a carrot-and-stick approach to motivation can encourage cheating, shortcuts and unethical behavior.

The VA reported that patient wait-time data had been falsified in two-thirds of its health care facilities. Organizational leadership failure, an unfocused performance measurement system, a toxic milieu, and unrealistically high goals, that placed undue pressure on staff and promoted unethical practices were cited as
key causes.

Several unintended consequences of the VA performance measurement system, mostly related to local implementation methods, were also described back in 2012 by Powell and colleagues.

Performance measurement faces even greater challenges in my own specialty, pediatrics. Pediatric measures tend to be predominantly process measures with sometimes less clear correlations with long-term clinical outcomes and population health. The evidence base for pediatric measures is even less mature than for adult measures, no pun intended.

Performance metrics are essential in tracking outcomes. You can only manage what you measure. And in health care, where demands on scarce resources are increasingly, quality measures are an indisputable way of figuring out which processes need to stay and which can go. Problems begin when performance measures cease to become a means to an end, and become an end unto themselves.

A Robert Wood Johnson Foundation-Urban Institute report advises strategic and parsimonious use of quality measures, recognizing when performance measures are not clinically valid or useful, and recognizing that performance measurement is just one aspect of a learning health care system.

My involvement these days with Central Line-Associated Bloodstream Infection (CLABSI) prevention is demonstrating to me even more strongly the importance of organizational context such as local culture, leadership styles, clinician engagement, and intrinsic motivation in applying quality measures. On hindsight, the training video on CLABSI measures that my team just finished working on probably needed to include a footnote on the perils and pitfalls of performance measurement. And that CLABSI is in essence a social problem that demands a focus not just on tracking infection rates, but on human behavior within complex and intense environments.

Front line clinicians need to remain accountable for their actions. However, leadership and an organizational culture that enforces rigid top-down measures without attention to providing resources and investing in developing people promotes the systemic infusion of unethical behavior and short cuts.

- Ulfat Shaikh

Measuring Improvement in Health Care from Ulfat Shaikh on Vimeo.