Pay for performance and motivation

An anonymous commenter on a post below asks:

Insurers have increasingly used pay-for-performance measure incentives for hospitals. Is there a sense that these will continue to expand?

I am not sure of the answer, but the question prompted me to give you a sense of the current P4P measures used by several of our private and government payers.

Here's a partial list:

Heart failure care processes (CMS measures)
AMI care processes (CMS measures)
Pneumonia care processes (CMS measures)
Surgical care infection prevention (CMS measures)
Patient experience with MD communication (H-CAHPS measures)
Patient experience with RN communication (H-CAHPS measures)
Patient experience with responsiveness of staff (H-CAHPS measures)
Patient experience with discharge planning and instruction (H-CAHPS measures)
Reducing surgical site infection -- colorectal population
Reducing surgical site infections -- GYN/hysterectomy population
Reducing surgical site infections -- orthopaedic trauma population
Reducing nosicomial catheter related urinary tract infections
Deploying rapid response teams (Triggers Program)
Preventing central line-associated bloodstream infections
Preventing ventilator associated pneumonia
Preventing pressure ulcers
Reducing MRSA infections
Preventing harm from high-alert medications
Preventing adverse drug events
Reducing surgical complications
Board of Directors training on quality and safety
Assessment of culturally/linguistically appropriate services
Assessment of health disparities

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. 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, many of which have clinical importance, we do so within an overall context that is meant to transform the organization.