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This presentation by Bureau of Health Information New South Wales CEO, Dr Jean-Frederic Levesque looks at the topic of incentives for quality improvement in the health system, specifically: - drivers of quality improvement and change in the health system - a structured way to look at incentives to improve performance - the challenges of attribution and monitoring.
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2014 IPHCRC Conference
Brisbane, March 19th 2014
Incentives for Quality Improvement:A case for alignments
Jean-Frédéric Lévesque, MD, PhD
MoneyWorks
MoneyMakesYouWork more
MoneyWorksSurprisingly
MoneyIsCostly
Information
TrainingOrganisation
Contracts
Peer pressure
Values LeadershipData
Money
Outline of the presentation
• Highlight some drivers of quality improvement and change
• Financial incentives are part of a mix of influences
• Propose a structured way to look at incentives to improve performance
• Levers act on different aspects of performance
• Discuss the challenges of attribution and monitoring
• Attributing results to providers, units or sectors require careful balance and trade-offs
Drivers of quality improvement and change
Levers for quality improvement
• External pressure
• Contracts, funding streams and policies (regulatory influences)
• Peer judgement or public reporting (normative influences)
What makes people change?
“What we know about gets attention”
“What we monitor gets done”
“What we pay for gets done more”
“What we report gets done now”
Levers for quality improvement
• External pressure
• Contracts, funding streams and policies (regulatory influences)
• Peer judgement or public reporting (normative influences)
• Internal motivation
• Knowing about own performance is a starting point (cognitive influences)
• Seeing the performance of others (mimetic influences)
What makes people change?
“What we know about gets important”
“What we monitor gets done”
“What we pay for gets done more”
“What we train for gets done better”
“What we report gets done now”
“What we see in others gets real”
A structured way to look at incentives
Paying for performance?
Performance refers to the actual production or enactment of a function. Actors perform on stage. Athletes perform in competitions. Surgeons perform in operating theatres.
In health care systems, performance refers to the provision of expected volumes and quality of services that meets the populations needs and expectations given the amount of resources invested.
A dynamic model of performance measurement
Incentives across dimensions of performance
• Clinically-relevant dimensions - amenable
• Productivity
• Accessibility
• Appropriateness
• Effectiveness
• Efficiency
Productivity : being organised, doing more
“Measurements of primary care volumes of services per resources invested: human and financial resources”
“Conformity to recognised best practice in organisational models of primary healthcare”
Accessibility: healthcare where and when needed
“Coverage of needs, unmet needs for care and avoidable higher levels of care of rostered population”
“Wait times and timeliness of care for patients presenting different urgency and complexity of care”
Appropriateness: The right healthcare, the right way
“Experience of care of patients receiving care”
“Proportion of patients in need for specific clinical interventions that are actually receiving it”
Effectiveness: making a difference for patients
“Reduction in complications and adverse events”
“Patient-reported outcomes measures”
Efficiency: value for money
“Avoidance of unnecessary and discretionary primary care services”
“Unit-costs of primary care services interventions”
Incentives across dimensions of performance
• Clinically-relevant dimensions - amenable
• Productivity
• Accessibility
• Appropriateness
• Effectiveness
• Efficiency
• Policy-relevant dimensions – less amenable
• Equity
• Sustainability
• Impact
The challenges of attribution and monitoring
Some challenges for incentives
• Performance is a nested process, enacted at the levels providers, organisational and system levels simultaneously
• Performance is a shared process in a context of complex diseases management processes
• Resources, processes and outcomes do not happen in the same timescales and indicators are limited in their capacity to capture temporal relationships
• Measurement in a context of incentives is a challenge
Enhancing incentives potential
• Relating measures of needs, resources, processes and outcomes to derive true constructs of performance
• Focusing on clinically relevant and specific measures of outcomes
• Understanding the reference (rostered) population
• Aligning incentives
• Stimulate productivity where more is always good
• Promote appropriateness when a clear guideline is available
• Relate access incentives with coverage
Return on the objectives
• Highlight some drivers of quality improvement and change
• Financial incentives are part of a mix of influences
• Propose a structured way to look at incentives to improve performance
• Levers act on different aspects of performance
• Discuss the challenges of attribution and monitoring
• Attributing results to providers, units or sectors require careful balance and trade-offs
Acknowledgements
• Kim Sutherland, Director, System and Thematic Reports, Bureau of Health Information
• Lisa Corscadden, Senior Researcher, Bureau of Health Information
• Efren Sempaga, Graphic designer, Bureau of Health Information
• Countless academics for your generous ideas about performance
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