BACKGROUND/RATIONALE:
There may be a number of unintended consequences of current approaches to defining, measuring, and reporting quality in primary care. Yet there is little empirical research documenting the existence of such effects, especially at the level of the patient-clinician encounter.

OBJECTIVE(S):
This research examined how the VA's clinical performance measurement (PM) system affects the practice of healthcare from the perspective of primary care staff. The specific objective of this exploratory study was to develop an in-depth understanding of positive and negative unintended effects of primary care clinical performance measurement on care delivery processes, on healthcare providers, and on patients.

METHODS:
We conducted a series of semi-structured in-person individual interviews of staff members at four VA facilities between February and July, 2009. Facilities were selected to assure variability in the number of veterans served and facility scores on national VA performance measures. A total of 60 interviews were conducted including 44 with primary care staff (14 physicians, 10 physician assistants/nurse practitioners, 14 intake nurses, 6 clinic nurse/physician managers) and 16 interviews with facility administrators (4 facility directors/chiefs of staff, 5 primary care service line leaders, 7 PM/quality improvement specialists). Interviews were recorded, transcribed and content coded to identify thematic categories, subtopics, and relationships.

FINDINGS/RESULTS:
The VA's national performance measurement system is implemented at the local level primarily through electronic clinical reminders, the allocation of primary care staff task responsibilities, and feedback systems. These implementation strategies play an important role in determining how PMs affect staff care decisions. Much of the burden to address PMs in clinic practice falls upon intake nurses. These nurses do not feel there is leeway for them to use their discretion in addressing PM related clinical reminders. Both nurses and physicians describe ways the PM system can make it difficult to adapt care to patients who are inappropriate for or refuse specific preventive health interventions. In many cases the clinical reminder cannot be "turned off" for these patients and therefore the same issues resurface on each patient visit. Several instances of "gaming" were described to achieve higher scores without actually improving care. Participants also indicated that pressure to meet performance measures can lead to care decisions that are inappropriate for the individual patient, such as polypharmacy. Participants also noted positive "halo" effects of PMs. For example, performance scores can be a source of pride and positive competition and incorporating preventive health PMs into the clinical encounter can send the message to patients that the VA cares about their whole health.

IMPACT:
Results of this study will be shared with VA Office of Quality and Performance and other VA leadership groups. This work is expected to influence how future generations of PMs are implemented into VA primary care settings.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Powell AA, White KM, Partin MR, Halek K, Hysong SJ, Zarling E, Kirsh SR, Bloomfield HE. More than a score: a qualitative study of ancillary benefits of performance measurement. BMJ quality & safety. 2014 Aug 1; 23(8):651-8. [view]
2. Powell AA, Saini SD, Breitenstein MK, Noorbaloochi S, Cutting A, Fisher DA, Bloomfield HE, Halek K, Partin MR. Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration. Journal of general internal medicine. 2015 Jun 1; 30(6):732-41. [view]
3. Saini SD, Vijan S, Schoenfeld P, Powell AA, Moser S, Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ (Clinical research ed.). 2014 Feb 26; 348:g1247. [view]
4. Powell AA, White KM, Partin MR, Halek K, Christianson JB, Neil B, Hysong SJ, Zarling EJ, Bloomfield HE. Unintended consequences of implementing a national performance measurement system into local practice. Journal of general internal medicine. 2012 Apr 1; 27(4):405-12. [view]

Conference Presentations

1. Powell AA, Partin MR, Halek KE, Christianson JB, Hysong SJ, Neil BJ, Bloomfield HE. A Qualitative Study of the Unintended Effects of Performance Measurement in VHA Primary Care. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
2. Powell AA, White KM, Partin MR, Halek KE, Christianson J, Hysong S, Neil BJ, Bloomfield HE. Unintended Effects of Performance Measurement in VA Primary Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]
3. Powell AA, White KM, Partin MR, Halek KE, Christianson JB, Hysong SJ, Neil BJ, Bloomfield HE. Unintended Effects of Performance Measurement in VA Primary Care. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN. [view]
4. Powell AA, White KM, Partin MR, Halek KE, Christianson JB, Hysong SJ, Neil BJ, Bloomfield HE. Unintended Effects of Performance Measurement in VA Primary Care. Poster session presented at: VA HSR&D Field-Based Quality Improvement in Parallel Circuits Meeting on VA System Redesign, Operational Systems Engineering, and Implementation Research; 2010 Jul 1; Indianapolis, IN. [view]

DRA: Health Systems Science
DRE: Treatment - Comparative Effectiveness
Keywords: Management, Organizational issues, Quality assurance, improvement
MeSH Terms: none