Background
Methods
Study design
Participants
Data collection
Data analysis
Results
Physician feedback model
Aspect of A&F | Component 1 Reaction | Component 2 Action | Component 3 Impact |
---|---|---|---|
Feedback Features | X | ||
Assessment Process | X | X | X |
Emotion | X | X | X |
Environment | X | X | |
External Locus of Control | X | ||
Core Values | X |
Topic | Number of Providers that Discussed Topic (Theme Groundedness) N (%) | N Times Topic Discussed in a Single Interview † (Min - Max) |
---|---|---|
External Locus-of-Control | ||
Financial Incentives (+) | 11 (92) | 1–3 |
Non-Compliant Patients (-) | 8 (67) | 1–5 |
Competition (+) | 6 (50) | 1–5 |
Lack of Consequences (-) | 6 (50) | 1–3 |
No Recognition of “Job Well Done” (-) | 4 (33) | 1–7 |
Management Style / Style of Delivery (+,-) | 3 (25) | 1–16 |
Emotion | ||
Frustration / Irritation (-) | 8 (67) | 1–9 |
Apathy (-) | 6 (50) | 2–5 |
Resentment (-) | 4 (33) | 1–3 |
Contentment / Pride (+,-) | 4 (33) | 1–5 |
Discouragement / Humility (+,-) | 3 (25) | 1–2 |
Embarrassment / Shame (+) | 2 (17) | 1–2 |
Procedural Justice of Assessment Process | ||
Unfairly Penalized (-) | 10 (83) | 1–14 |
Small Sample Charts Reviewed (-) | 6 (50) | 1–6 |
Unaware of Measures Being Tracked (-) | 4 (33) | 1–6 |
Feedback Features | ||
Feedback Content (+,-) Aggregated vs. Personalized Data | 8 (67) | 1–16 |
Feedback Temporality (+,-) Timely vs. Untimely Delivery | 7 (58) | 1–13 |
Feedback Source (+,-) Respected vs. Not Respected Individual | 3 (25) | 1–6 |
Environment | ||
Time Constraints / Patient Volume (-) | 10 (83) | 2–8 |
Inadequate Resources (-) | 4 (33) | 1–4 |
Quality Clinical Team (+) | 1 (17) | 1–2 |
Stress / Cognitive Overload / Burn-out (-) | 2 (25) | 1–3 |
Core Values | ||
Desire to Help Patients (+) | 8 (67) | 1–4 |
Performance Good Enough (-) | 4 (33) | 1–4 |
Component 1 – Reaction
Feedback characteristics
We complained a few months ago that we wanted to see more individualized provider reports … There’s no provider-specific data. (Physician 9).They screen performance so frequently you don’t stay in a downward trend for long. They identify which plates are about to fall, and they’ll let you know. I’d rather they do that than one day come in and say, ‘Hey, your performance measures over the past 6 months totally suck’ (Physician 6).They don’t understand how many hours we put in here. They don’t understand how many patients we have … They don’t understand the work involved with each patient. They just care that your numbers are down. (Physician 8).
Performance assessment process
They review Hemoglobin A1C… something that is supposed to be checked yearly. If the patient was not here in the last year or does not go to the lab, how can we check their A1C? We give them the card … you can see in the record it was ordered several times … but they don’t go to the lab. We have no control over patients … they don’t comply… but we get penalized for it. (Physician 9)
Emotion
When we receive the monthly report and see how you are doing compared to the other teams, you feel good knowing that you’ve done a good job. (Physician 8)
Component 2 - Action
Action Type | Definition | Examples of Actions Taken |
---|---|---|
Retroactive Acts | The physician revisited previously seen patients to correct an identified problem | Contact patients who did not come in for a scheduled office visit to reschedule the appointment. Contact patients who were given an order for a test or procedure, but has not gotten the test/procedure, to remind them of the importance of the test. |
Proactive Acts | The physician focused on future, rather than previously cared for patients | Contact patients who have an upcoming appointment to remind them of the appointment. Physicians developing tools to track their patients and performance. Providing patients with education and/or tools to better manage their disease (i.e. provide them with blood pressure equipment). |
Defensive Acts | The physicians attempted to justify their specified level of performance. The defensive approach was often used when physicians felt there was an external locus of control (or factors outside their control such as non-compliant patients) that impacted their performance. | Provide management with an explanation as to why performance was low. This approach often required extensive research to identify and document the factors associated with low performance. Along with the explanation for low performance, many (4 of 12) physicians offered improvement suggestions. |
Performance assessment process
The N is incredibly tiny. These patients may not be representative of our typical patient, yet these numbers are taken very seriously. There’s a lot of things on EPRP that don’t always get reported, so we don’t always know what’s being tracked. The major focus has always been on diabetics measures. The other things were not as frequently brought to our attention. (Physician 12)
Emotion
When you receive the list and see you have fallen out, the first step is look at the cases and see if there’s any reason why we should provide a rebuttal. We feel like we have to defend why measures fall out. (Physician 11)
[In meetings where performance is openly discussed] You have to be willing to be humble enough to say, ‘Hey, it seems like me and one other person here are the only ones in red all the time, so I would like to know what you all are doin’ to keep levels up?’ … It’s interesting because you get a feel for what others are doin’, so you can correct what you are doin’. (Physician 1)
I think, basically, EPRP helps a lot in defining the criteria. You know where you are standing in relation to others. I think the higher you score, the better you feel. You want to maintain that level so you try to do all you can to keep on top. (Physician 5)
For the most part, my numbers are usually in the middle, around the average… near the bar… I always feel like if I’m within one standard deviation of the bar, I can live with that. (Physician 3)
Environmental factors
The biggest glaring deficit that we have is staffing … We are working with less than a skeleton crew - we’re a skeleton crew minus one rib per skeleton …We are always going to be getting more patients and, if they continue to hold fast to this idea that when one leaves we cannot replace them, we’re gonna be facing a lot of difficulties keeping up with our measurements. I don’t think it’s reasonable. (Physician 6)
Component 3 - Impact
External locus-of-control
You are in at the end of the day because the performance pay is based on how you perform on your performance measures. (Physician 7)Healthy competition is good. My team does really well with the performance measures. When we get that monthly review and you see how the other teams are doing, you feel good just knowing that you’ve done a good job. It makes you feel better, and you want to do more. (Physician 8)
Sometimes it’s demeaning the way they treat you … you’re an adult after all. That was the way the person that we had before was. It doesn't make you feel very good. So, basically, my mechanism is ignore negative feedback or any sly remarks. I had a situation where there was something I didn’t do. They went to the top boss, and he got angry. Well, the new person is like, “Hey, you know, I wanted to remind you you’ve got to do this. Somehow it went to upper management, and I know it’s kind of embarrassing, but, you know, can you do it?” I’m like, “Yeah, sure”, and I did it that night. It was the same problem, but it was presented in a ‘helping each other out’ manner. (Physician 4)
Core values
The reason I provide good care is for the patients, not because I’m gonna get more money. I guess I’m a kind of a purist like that. I wanna provide good care because that’s what we should be doing. (Physician 8)
Emotion
Environmental factors
Primary care is very dynamic and challenging because there’s precious few providers, even fewer coming down the pike, and more and more demands from the patient population burgeoning. We’re getting 500 new patients a month; and the average provider here is running 105-115 % of their expected empanelment, so nobody’s happy because everybody’s being squeezed, and there’s a hiring freeze and the budget is terrible and so on and so forth… (Physician 12)