By: Peter M. Fleischut, MD, assistant professor of anesthesiology, Department of Anesthesiology, Weill Cornell Medical College, and deputy quality and patient safety officer, New York-Presbyterian Hospital
The social and political landscapes have seen a shift in attention towards the current conditions of healthcare accessibility, cost, and value. With the implementation of healthcare reform, greater emphasis has been placed on the quality of medical care, and associated metrics such as, HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) scores, as well as its associated costs. Within these efforts, the Medicare payment structure now bundles payments based on diseases treated and withholds payments for errors. This model shifts the focus to incentivizing the provision of quality care. With this new paradigm, many institutions have begun to implement quality improvement initiatives to improve care, patient outcomes, and patient safety, which can be demonstrated through collection and analyses of quality metrics. The engagement of all physicians, including those in training, is an essential key component of these initiatives.
Overall, residents have remained largely disengaged in quality improvement initiatives, which is troubling because the success of quality initiatives is often all about engagement. Several national and government organizations, including the Accreditation Council for Graduate Medical Education (ACGME), newly require the involvement of residents in quality projects. A number of new models have emerged to include trainees in the improvement in quality of care, including, incentives for resident performance or creating mechanisms to promote more active participation of housestaff, such as a Housestaff Quality Council (HQC). At NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC), an HQC was created to promote a culture of greater participation of housestaff in quality and patient safety. Important steps to foster and sustain engagement include:
- ensuring buy-in through involvement in policy making,
- disseminating knowledge to peers,
- enforcing best practices, policies, and development of relationships,
- communicating key changes, and
- sharing data of quality metrics.
Physician and resident engagement not only garners support, but also educates providers on evidence-based practices and hospital-wide process improvement efforts. Another model to promote and maintain resident engagement has been to develop a pay-for-performance (P4P) system. One institution’s P4P model is highlighted in a recent article by Dr. Vidyarthi and colleagues: “Engaging Residents and Fellows to Improve Institution-Wide Quality: The First Six Years of a Novel Financial Incentive Program.”
A P4P system has many benefits and may lead to greater physician engagement. The program’s structure provides incentives to participants that may not have been previously engaged in quality initiatives and fosters a friendly competition between peers to meet or exceed stated goals. This exposes young physicians to quality improvement projects, perhaps for the first time, which may promote new ideas and collaborations to develop creative and innovative ways to improve quality and patient safety on a broader scale.
Conversely, this shift has raised questions as to the acceptability of pay-for-performance incentives among residents and fellows. Critics of a P4P model feel residents and fellows should focus on learning; financial incentives may distract them from their duty to learn to an initiative that will financially reward their efforts. Additionally, financial incentives may lead to the meeting of quality goals, but do other initiatives or responsibilities suffer? When and if the incentive disappears, will the quality of care also wither? Further study is necessary to determine if the quality improvement initiatives under a pay-for-performance model reach a ceiling once the goal is met and what incentive is required at that point to surpass the stated goal. Additionally, further scrutiny may be necessary to determine if other initiatives suffer due to a refocusing of efforts on paid incentives. There are concerns with the pay-for-performance model; however, there are also issues with a model such as the HQC, chosen by NYP/WCMC. The HQC model has shown some difficulty maintaining engagement due to communication issues. Effective communication cannot be underestimated. A multimodal form of feedback to housestaff is key to addressing this problem.
P4P models related to quality initiatives may be a viable option for institutions and may be the future reimbursement structure from insurers. However, the model of providing financial incentives should be approached with caution. Institutions should approach the implementation of any quality initiative thoughtfully. If the pay-for-performance model is chosen, financial incentives must be directed carefully to key measures that align with institutional goals. Stipends should be balanced appropriately to prevent participants from focusing only on financial incentives, which potentially could be detrimental to educational objectives and clinical duties.
Regardless of the model chosen to improve quality of care and patient safety, participants need to be educated appropriately regarding the science behind quality improvement in order to be fully engaged in the process. This engagement and education is paramount to the success of any initiative to improve quality of care.