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ORIGINAL RESEARCH
Unintended Consequences of Implementing a National Performance Measurement System into Local Practice
Adam A. Powell, PhD1,2, Katie M. White, EdD3, Melissa R. Partin, PhD1,2, Krysten Halek, MA1, Jon B. Christianson, PhD3, Brian Neil, MD4, Sylvia J. Hysong, PhD5,6, Edwin J. Zarling, MD7, and Hanna E. Bloomfield, MD1,2
1Core Research Investigator, Center for Chronic Disease Outcomes Research (CCDOR)( Minneapolis VA Health Care System, Minneapolis, MN, USA; 2Department of Medicine( University of Minnesota, Minneapolis, MN, USA; 3School of Public Health( University of Minnesota, Minneapolis, MN, USA; 4VA Midwest Health Care Network, VISN 23, Minneapolis, VA, USA; 5Houston Center for Quality of Care and Utilization Studies( Michael E. DeBakey VA Medical Center, Houston, TX, USA; 6Baylor College of Medicine, Houston, TX, USA; 7North Chicago Captain James A. Lovell Federal Health Care Center, North Chicago, IL, USA.
BACKGROUND: Although 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, APPROACH: Qualitative 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.
RESULTS: Participants 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...