Table 2 Typology of Unintended Consequences of Performance Management in Healthcare
Type | Description | References | In Our Data? |
|---|---|---|---|
Unintended Consequences on Providers and Organizations | |||
I. Increased Work | |||
a. Increased administrative burden | Excessive time spent on administrative tasks (e.g., documentation, data collection and submission, justifying deviation from clinical reminders when not clinically relevant) | ✓✓ | |
II. Poor Design or Use of Performance Data | |||
a. Tunnel vision | Emphasis is placed on dimensions of performance that are measured or incentivized, while other unmeasured but important aspects are overlooked | ✓✓ | |
b. Measure fixation | Emphasis is placed on meeting the performance target rather than the associated objective | ✓✓ | |
c. Suboptimization | Focusing on one component of a total and making changes intended to improve that one component and ignoring the effects on other components (e.g., pursuit of narrow local objectives at the expense of broader organizational or system objectives) | ✓ | |
d. Myopia | Excessive concentration on short-term targets without consideration for long-term consequences | ✓ | |
e. Quantification privileging | Fixation on data that can be quantified causing qualitative aspects of healthcare to be missed | ✓ | |
f. Anachronism | Lag effect between data capture and data usage causes data to not help solve current problems | [5] | ✓ |
g. Insensitivity | Assessment does not capture overall complexity of health performance, causing the wrong providers, units, or organizations to be penalised or rewarded (e.g., contextual factors not considered, risk adjustment not performed, good performance results in a disadvantage such as improved efficiency and cost savings resulting in a lower budget the following year) | ✓✓ | |
h. Misinterpretation | Incorrect inferences made about raw performance due to a lack of understanding of the measure and its underlying methodology or to a failure to account for the full range of possible influences on performance | ✓ | |
i. Complacency | Reduced ambition to improve caused by the perception that performance is satisfactory | ✓ | |
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) | ✓ | |
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 | ✓ | |
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) | ✓ | |
b. Gaming | Deliberate manipulation of behavior to appear a better performer (e.g., cherry-picking patients, stopping the clock for wait time indicators) | ✓ | |
c. Bullying | Pressure for performance improvement involves shaming, intimidating, or coercing staff; PM system seen as punitive and oppressive | ||
d. Loss of professional ethos/morality | PM causes provider motivation to shift from providing the best care to providing incentivized care, thereby undermining providers’ intrinsic motivation | ||
e. Reduced learning and psychological safety | A work environment focused on blame emerges and generates distrust and fear that inhibits problem-solving, learning, and innovation | ||
f. Reduced autonomy, agency and/or self-regulation | PM reduces individual, organizational, or network autonomy, agency, and ability to self-regulate due to the PM system itself and/or due to how PM was implemented (i.e., imposed on providers, rather than designed and undertaken with or by them) | ✓ | |
g. Reduced morale | Loss of belief and confidence in their organization’s mission, goals, or work or loss of belief and confidence in PM tools and processes | ✓✓ | |
h. Team and inter-professional conflict | Reduced cooperation and increased tension between teams and professional groups due to PM | ||
i. Increased perceived injustice (due to social comparisons) | Feelings of competition, resentment, and frustration between those individuals and groups who are affected by PM and those who are not (e.g., those not affected by PM do not receive the same attention and/or resources; those affected by PM operate under more scrutiny and pressure) | N/A | ✓ |
j. Toxic ambition | Constant pressure to improve even when performance meets or exceeds the target | N/A | ✓ |
IV. Exacerbation of Inequities | |||
a. Increased resource gap | Providers that treat poorer or underserved patients may have less resources to invest in improvement. As a result, they perform worse and then either do not benefit from incentives or experience penalties that further exacerbate existing resource gaps | ✓ | |
b. Reduced ability to recruit necessary staff | Staff are attracted to highly rated organizations compared to lower rated organizations thereby making it more difficult for lower rated organizations to recruit staff and improve performance | ||
c. Overcompensation | Incentive payments made are higher than required to meet performance targets, thereby reducing resources for other important types or aspects of care | [5] | |
V. Politicization of Performance Management | |||
a. Political grandstanding | PM is driven by interests of governments, political parties, the media and other stakeholders | [5] | |
b. Political diversions | PM is used as a distraction by governments under pressure | [5] | |
VI. Positive Unintended Consequences | |||
c. Improved morale | Feeling of recognition and increased confidence and pride in individual or organizational performance | ✓ | |
d. Motivated learning and development | PM spurs further education and training to support improvement | ✓ | |
e. New relationships and collaborative problem-solving | Professionals, organizations, or networks come together in new and inventive ways to cope with PM | ✓✓ | |
f. Improved capacity planning | Information collected through PM allows for better internal planning and external applications | N/A | ✓ |
Unintended Consequences on Patients and Patient Care | |||
I. Inappropriate or Sub-Optimal Care | |||
a. Clinical decisions driven by PM (rather than by evidence and clinical judgment) | PM generates pressure to diagnose and treat patients in particular ways, resulting in under-treatment, over-treatment, and/or harm to patient | ✓ | |
b. Improved documentation without improved care | Providers document care provided more effectively, but the care itself is not improved | ✓ | |
c. Less continuity of care | When PM incentivizes approaches to care that result in patients interacting with multiple providers rather than or in addition to their primary provider(s) (e.g., incentives for same-day appointments and after-hours care) | ||
II. Reduction in Patient-Centered Care | |||
a. Compromised patient education and treatment choice | Providers promote incentivized treatments over non-incentivized treatments to patients or fail to obtain informed consent before conducting a test or procedure | ✓ | |
b. Compromised patient autonomy | Providers exert pressure on patients who refuse incentivized care | ✓ | |
c. Compromised patient convenience | Causing inconveniences for patients for purposes relating to PM (e.g., requiring an additional appointment that would otherwise not be deemed necessary or bringing up a topic like end-of-life care at an inappropriate time and place) | ✓ | |
d. Compromised patient engagement | Reduction in patient engagement as a result of changes in treatments driven by PM | [65] | |
e. Disregard for the patient voice | Providers give less attention and priority to patient concerns and preferences compared to PM-related aspects of care | ✓ | |
f. Erosion of trust in care | Patients lose confidence in their healthcare providers after a poor performance assessment or after experiencing or witnessing manipulation driven by PM | ||
II. Exacerbation of Inequities | |||
a. Increased inequity in access to high quality care | Providers avoid high risk or socially challenging patient sub-groups or choose patients who can maximize positive measurement (i.e., cherry-picking) When financial incentives for high performance are re-invested in improved services, then patients of high-performing services benefit to a greater degree than patients of under-performing services | ✓ | |
b. Increased healthcare disparities | Increased health care disparities in the population based on sex, race, ethnicity, language, or economic status due to (1) differences in access to high quality care or (2) improvements spurred by PM are more useful to mainstream patients | ✓ | |
IV. Positive Unintended Consequences | |||
a. Beneficial spillover effects | PM contributes to improved performance in other clinical areas that are not performance managed | ||
b. Increased patient knowledge | PM increased patient education efforts | [61] | |
c. Increased patient motivation and engagement with care | Patients more involved and compliant with recommended care due to increased education and time spent | [61] | |
d. Increased patient satisfaction with care | PM promoted more comprehensive care (e.g., addressing multiple issues per visit, including preventive care) | [61] | |
e. Enhanced patient-provider communication and relationships | PM increased patient-provider communication, resulting in positive psychological feelings among patients regarding their providers and their care | ||