Tuesday, October 07, 2014

P4P: The bureaucracy of documentation

Way back in 2010, I raised serious doubts about the efficacy of the pay for performance metrics that were being imposed on hospitals by private and public payers.  After listing the multitude of such metrics, I asked:

If you were in a management position and were trying to direct quality and safety improvement efforts, how would these guide your behavior? If your were a nurse or doctor and were trying to be responsive in focusing on quality and safety improvements, what would this variety of measures tell you?

Let me jump to the answers: The large number of overlapping measures, often with different definitions among payers, can cause confusion rather than offer guidance to hospitals in directing improvement efforts. That is especially the case because many of the items are "roll-ups" of several metrics in themselves.

In this respect, P4P measures are not always the most useful management tools by which to focus attention on the fundamental elements of process improvement: reduction in variation, redesign of work, and communication in clinical settings -- all in collaboration with patients and families. 

Well, a new JAMA report reaches conclusions that are even more strikingly set forth.  The commentary notes:

The findings of a study presented in this issue of JAMA Internal Medicine reinforce concerns about the unintended consequences of public reporting and pay for performance and also suggest a gap between quality improvement activities and patient care. Lindenauer et al surveyed hospital leaders (chief executive officers and executives responsible for quality) about publicly reported quality measures required by the CMS. Although most respondents said that they used the measures extensively, more than half were concerned that the measures encouraged teaching to the test, and almost half reported trying to maximize performance primarily through changes in documentation and coding. Also important is that half or more believed that the CMS measures did not meaningfully distinguish among hospitals or accurately reflect quality of care, even for conditions specifically targeted by the measures. In short, the study findings suggest that many hospital leaders doubt the clinical relevance of these measures. This skepticism is consistent with national data: studies of public reporting and pay-for-performance programs in the United States have failed to demonstrate a clear connection to improved quality.

Indeed, as you see from this excerpt, there is concern that P4P metrics actually distract the hospital and doctors from the things that matter, by focusing on the bureaucracy of documentation.

Where does this leave us?  Well, we need to go back to the underlying values that motivate doctors and nurses, a desire to alleviate human suffering caused by disease.  As I concluded back then:

People who have studied how to achieve change in organizations point to the need for an overarching, audacious set of goals that are highly motivational.

In our case, the most important established goal is to eliminate preventable harm, one endorsed by our Board of Directors. This goal is combined with a strong commitment to transparency, so we hold ourselves accountable to the standard we have set. So, while we will always do our best to meet P4P requirements . . . we do so within an overall context that is meant to transform the organization. 


e-Patient Dave said...

Paul, of course I agree with all of this. It keeps coming back to this:

A whole lot of people in the business just don't give enough of a rat's patoot to do anything about it, and there is no enforcement that gives these people consquences that are annoying enough to change their behavior.

You and I continue to appeal to the inspiring side of people's nature, and while an increasing number are doing the good work and improving, there continues to be no license revokation or major fines except in the worst worst cases. In fact, the nasty truth remains that the people who experience consequences are the patients who are harmed or die, and the families who suffer. (And society paying the bills.)

Got any suggestions?

Paul Levy said...

Dear MD. I didn't get your first comment. Please resubmit, and I will post it.

Anonymous said...

Dave, you are missing the point of the article, which is that much time and resources are consumed by the documentation of mostly unimportant data that would be better used for meaningful efforts toward improving patient care. The clipboard people have chosen "quality indicators" that must be documented at every patient encounter that are easy to measure, not that are important to care. I care much more about my doctor's clinical acumen than I do about whether she ascertains (and documents) at every visit that I continue to consistently wear my seatbelt and feel safe in my relationships, but these are the things the clipboard people look for because they're easier than assessing clinical excellence.

I am truly sorry, Dave, that you feel that no one gives a rat's patoot about excellent patient care unless we have the threat of license revocation or fines hanging over our heads. It is well known that punitive cultures do not inspire excellence. You ever hear the expression "they couldn't pay me to do this?" Well, that's being a physician--our reward is in seeing our patients do well. As one of the many who took care of you a few years ago, I am actually quite distraught and maybe a little offended that you were left with that impression.