Measurement fatigue: The backlash

Anyone who’s been in the hospital infection prevention business for any length of time is familiar with a specific form of cognitive dissonance. We believe, on the one hand, that the publicly-reported, metric-focused, pay-for-performance (PFP) environment has brought increased resources to infection prevention and resulted in a real decrease in healthcare-associated infections (HAIs); yet we believe, on the other hand, that these high stakes have led to a number of unintended adverse consequences, including gaming of HAI definitions, an unhealthy focus on measures that may not merit the resources and attention, and have engendered cynicism as it becomes apparent that PFP measures may not correlate with actual quality or value.

Over the past week, I’ve read three pieces that make me wonder if we’re reaching a tipping point, as clinicians begin to push back effectively against the proliferation of “measures”, “metrics”, “performance targets” (whatever you wish to call them), in an attempt to seek a balance between them and the words of Francis Peabody, that “the secret of the care of the patient is in caring for the patient.” I’ve pasted some key quotes below from each of these pieces.

First, an excellent opinion piece from Dr. Robert Wachter in the New York Times:

"All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures….

....Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields."

Next, from a fascinating report of hospitalists unionizing in Oregon:

"To work in a hospital today is to be constantly preoccupied with money, and one of the more grating features as far as the Sacred Heart hospitalists are concerned has been the administration’s celebration of “skin in the game.” That means creating financial incentives for doctors to hit performance targets — like lowering patient’s length of stay and doing well on patient satisfaction surveys. The phrase entered the Sacred Heart lexicon in 2014, but the underlying concept has spread throughout the profession in recent years…. 

…the increasing focus on metrics like readmission rates and hospital-acquired infections had created more work for hospitalists, who are responsible for a lot of documentation."

And finally, from a NEJM piece on “Taylorism” in medicine:

"Instead of gaining happiness minutes, clinicians are increasingly experiencing dissatisfaction and burnout as they’re subjected to the time pressures of Taylorism and scientific management in the name of efficiency. We have watched colleagues fleeing to concierge practices, where they have control over their schedules. Others have taken early retirement, unwilling to compromise on what they believe is the time needed to deliver compassionate care. Some have moved into management or consulting positions, where they tell others how to practice while unburdening themselves of their clinical load. Just as Taylor enriched himself by consulting for companies, a growing and lucrative industry has emerged to generate and enforce metrics in medicine. By 2014, the Centers for Medicare and Medicaid Services alone had mandated the use of more than 1000 performance measures. As the Institute of Medicine recently reported, such metrics have proliferated, though many of them have little proven value."

(This last piece probably should have given a shout-out to a piece by Mike that started by similarly invoking Frederick Winslow Taylor.)