Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Telling Us

Herzer, Kurt; Pronovost, Peter J.

doi:10.1016/s1553-7250(15)41069-4

Cited by 22 publications

(19 citation statements)

References 47 publications

(54 reference statements)

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“…We adapted Herzberg's motivation-hygiene theory 11,12 for our classification system. Herzberg's theory posits that extrinsic motivators exist outside an individual (eg, money and status) while intrinsic motivators exist within an individual with effort linked to the level of interest in the work being performed (eg, purpose, responsibility, and learning).…”

Section: Variablesmentioning

confidence: 99%

Motivation for Participation in the American Board of Family Medicine Certification Program

Peabody

Peterson

Dai

et al. 2019

Fam Med

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Background and Objectives: Board certification programs have been criticized as not relevant to practice, not improving patient care, and creating additional burdens on already overburdened physicians. Many physicians may feel compelled to participate in board certification programs in order to satisfy employer, hospital, and insurer requirements; however, the influence of forces as motivators for physicians to continue board certification is poorly understood. Methods: We used data from the 2017 American Board of Family Medicine (ABFM) Family Medicine Certification Examination practice demographic registration questionnaire for those seeking to continue their certification, removing physicians who indicated they did not provide direct patient care. We utilized a mixed-methods design. For the quantitative analysis, a proportional odds logistic regression was used to examine the association between predictor variables and increasing levels of external motivation. For the qualitative analysis, we used a deductive approach to examine open-text responses. Results: Of the analytical sample of 7,545 family physicians, approximately one-fifth (21.4%) were motivated to continue their board certification solely by intrinsic factors. Less than one-fifth (17.3%) were motivated only by extrinsic factors, and the majority (61.2%) reported mixed motivations for continuing their board certification. Only 38 respondents (0.5%) included a negative opinion about the certification process in their open-text responses. Conclusions: Approximately half of family physicians in this sample noted a requirement to continue their certification, suggesting that there has been no significant increase in the requirements from employers, credentialing bodies, or insurers for physicians to continue board certification noted in previously cited work. Furthermore, only 17.5% of our sample reported solely external motivation to continue certification, indicating that real or perceived requirements are not the primary driver for most physicians to maintain certification.

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Section: Variablesmentioning

confidence: 99%

Motivation for Participation in the American Board of Family Medicine Certification Program

Peabody

Peterson

Dai

et al. 2019

Fam Med

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“…The most effective quality improvement initiatives address clinicians’ intrinsic motivators – their drive for achievement, sense of purpose, autonomy, responsibility and desire for learning . Physicians appear to care about their performance relative to their colleagues, and this comparison may provide a compelling motivation to help change an individual clinician's practice . This is analogous to the use of the Greenie Board feedback system in the US Navy, where the competitive nature of naval aviation is enhanced by displaying the pilots’ grades publicly – and pilots that record too many reds may be considered unsafe for an ongoing career as a Navy pilot .…”

Section: Discussionmentioning

confidence: 99%

The enhanced recovery after surgery (ERAS) Greenie Board: a Navy‐inspired quality improvement tool

et al. 2018

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The United States Navy uses a visual feedback system for pilots, named 'the Greenie Board', to improve flight manoeuvres on aircraft carriers. Given that increased compliance with enhanced recovery after surgery protocols reduces postoperative complications, we decided to apply a similar feedback system to our institutional enhanced recovery programme. We undertook a prospective 12-month audit of 194 patients assigned to our enhanced recovery programme and evaluated adherence to the anaesthesia-related components of our protocol, before and after implementing a Greenie Board. A compliance score was calculated by summing points for adherence to: intra-operative antibiotic prophylaxis; temperature management; goal-directed intravenous fluid therapy; postoperative nausea and vomiting prophylaxis; and postoperative fluid restriction. The score for each patient was then colour-coded and anonymously displayed for each anaesthetist on a Greenie Board within the operating theatre suite. Protocol adherence improved significantly following introduction, with 'Green' scores (acceptable compliance) increasing from 33% to 72% of patients (p < 0.0001). The greatest improvement was seen with anti-emetic prophylaxis (49% to 70%, p = 0.004) with a consequent reduction in postoperative nausea and vomiting (OR 0.42, 95% CI 0.19-0.88, p = 0.021). We did not observe a decrease in other postoperative complications nor hospital length of stay. We conclude that this US Navy-inspired feedback system is an easily implemented, low-cost quality improvement tool that significantly improved adherence to intra-operative components of our enhanced recovery protocol. The system lends itself to global scaling to drive quality improvement in healthcare delivery and would be suited to institutions without electronic medical records, including low-resource countries.

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“…If we "measure the measures" in the United States and the United Kingdom, despite nearly 15 years of various measurement programs, there is no clear evidence that our efforts have moved us significantly closer to the Quadruple Aim. 45 In neglect of this principle, quality programs in primary care have overemphasized the dissemination and collection of metrics, while largely ignoring their impact on costs and providerpatient experiences. This neglect is one of the sources of our current quality crisis.…”

Section: Principle 2: the Quadruple Aim Is A Dynamic Whole Not The Smentioning

confidence: 99%

“…old biomedical, process-oriented paradigm, these forms of extrinsic motivation often sap providers' intrinsic drive to improve patient outcomes and can lead to "gaming" of the system. 47 Despite robust documentation of the limitations of extrinsic programs, such as P4P, 4 and despite compelling evidence that intrinsic motivation improves patient outcomes, 45,[47][48][49] policymaking has focused predominantly on the former at the expense of the latter. Even programs like the Physician Quality Reporting System in the United States (now assimilated into MACRA), which attempts to integrate intrinsic motivation through providers' free choice of metrics, remains extrinsic in design and implementation.…”

Section: Principle 3: Measurements Are Tools For Quality Not Outcomementioning

confidence: 99%

Core Principles to Improve Primary Care Quality Management

et al. 2018

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Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim.

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Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Telling Us

Cited by 22 publications

References 47 publications

Motivation for Participation in the American Board of Family Medicine Certification Program

Motivation for Participation in the American Board of Family Medicine Certification Program

The enhanced recovery after surgery (ERAS) Greenie Board: a Navy‐inspired quality improvement tool

Core Principles to Improve Primary Care Quality Management

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