• Bottom-Up Measurement: A Key to Physician Engagement

    Oct 20, 2014

    Pay-for-performance tactics will only work with physicians if they own the metrics and are invested in the organization’s culture.


    When North Carolina teachers pushed back against their school district’s pay-for-performance approach, a savvy official tried another tactic, says Gurpreet Dhaliwal, MD, professor of clinical medicine at the University of California San Francisco (UCSF) in a Leadership video excerpt.

    “He went back to the teachers and said, ‘OK, why don't you tell me what should be measured?’

    “What he got was an engaged profession. He actually got teachers to say, ‘This is what we should measure, this is how we should measure it, this is who should measure it, and this is what we should do with the data.’”

    By using a bottom-up approach to measurement, the school official found the secret sauce of engaging professionals in performance improvement—a lesson that can be applied to physician engagement activities, Dhaliwal said during a presentation at the 2014 ANI, The HFMA Annual National Institute.

    First, Illustrate the Power of Measurement

    Referring to a seminal NEJM article on the topic, Dhaliwal draws parallels between pay-for-performance in education and health care. Because physicians, like teachers, are “not wired around being measured,” healthcare leaders need to bring them along step by step. The first step is to enlist physicians in identifying the relevant metrics. This hands-on approach helps physicians learn for themselves the power of using performance metrics to improve patient outcomes.

    Going back to the school district example, Dhaliwal points to several things the school official did right. He asked for the teachers’ professional expertise, but importantly, the official reprogrammed the professional identity of the teachers. He helped them see that a professional doesn’t just go about doing their work; they go about doing their work better.

    Then Create a Shared Purpose Organization

    Once physicians agree to be measured, the next step is to help them to change their practices so performance improves. “Humans need two things to be in place before they change their behavior. There has to be emotion and there has to be context.”

    Specifically, Dhaliwal recommends using the benefits of peer pressure to influence physicians. “The human drive to be in sync with others is very, very strong. And then, if you're in this hyper-competitive subspecies of doctors, you don't just want to be in sync, you tend to want to be ahead of the pack—and that competitiveness can be used in a good way.”

    He provides two pieces of advice:

    Performance results should be semi-public. “It doesn't need to be on the World Wide Web, but it needs to be internally public. That is to say on a bulletin board in a back hallway, in an email message, or at a staff meeting. If there is no healthy comparison, you won't engender that social pressure. But the person at the helm has to do it just right ... so it doesn't engender resentment or embarrassment.”

    Physician comparisons have to be local. “If social pressures are present from local forces, what was once a hassle?washing my hands, working in teams, keeping track of my readmissions?starts to become a habit.”

    Over time, these approaches will help change an organization’s culture, creating what Dhaliwal calls a shared purpose organization. “What is culture? Culture is what you talk about, what you believe, and what you do. If everyone is starting to talk about improving performance and all of our outcomes start to point in the same direction, then we start to see the scaffolding of a shared purpose organization.”

    Only Then, Tie in Financial Incentives

    Dhaliwal does not believe pay-for-performance incentives with physicians will work until a shared purpose organization is created. “A shared purpose organization is a precondition for using financial incentives, but financial incentives will never ever build a shared purpose organization,” he says. “You have to have the culture first.”


    Gurpreet Dhaliwal, MD, is professor of clinical medicine at the University of California San Francisco.

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