Quality improvements: Rewarding the signal and not the noise

In my post yesterday I questioned whether our current incentives are truly promoting quality or just prettier looking documentation. I used Dan Ariely's discussion on the fallacy of rewarding outcomes in the world of business as a jumping off point. But today it occurs to me that some of his suggestions about changing course to start moving in the direction of best achievable quality need to be further adapted to healthcare environment. So, I will try to do it here, and would love feedback, if you have any.

Here are Dan Ariely' recommendations on how to start rewarding the signal instead of noise:

1. Change the mind-set. Publicly recognize that rewarding outcomes is a bad idea, particularly for companies that deal in complex and unpredictable environments.

2. Document crucial assumptions. Analyze a manager’s assumptions at the time when the decision takes place. If they are valid but circumstances change, don’t punish her, but don’t reward her, either.

3. Create a standard for good decision making. Making sound assumptions and being explicit about them should be the basic condition for getting a reward. Good decisions are forward-looking, take available information into account, consider all available options, and do not create conflicts of interests.

4. Reward good decisions at the time they’re made. Reinforce smart habits by breaking the link between rewards and outcomes.

I think that I need to deconstruct some of them to make them applicable to healthcare. So, here are my healthcare equivalents of culture and incentive change, so that we can start focusing on better care.

1. Change the mind-set -- This applies to public reporting of never events. Tracking these on a large scale, say, city, state, country, is necessary so that we know how we are doing at not inflicting harm. However, at the level of an individual institution, there is so much variability in events such as infections, mortality, etc., that using them as a public humiliation tool is not sensible.

2. Document crucial assumptions -- We can adapt this to a healthcare setting to reflect how we build our systems to maximize prevention efforts. That is, in the setting of perpetually imperfect and oftentimes substandard evidence, in addition to tremendous inter- and intra-patient variability, a sensible evaluation of how best to approach each patient in the context of preventing complications is needed. If the evidence for interventions is valid, but the circumstances of how we understand the patient's condition change, we should not either reward or punish the provider or the institution for the associated outcome.

3. Create a standard for good decision making -- This is pretty easily adapted to our setting. Transparency, being up to date on the evidence, as well as the information on the particular patient, considering all that is reasonably available, and without conflicts of interest, are all part of the mandate for intentional quality improvement and individualized care. This also sets the criteria for what good decision support should look like.

4. Reward good decisions at the time they are made -- No translation necessary here, I think. The only thing I want to say is that there are ways other than financial to reward good performance, and we need to understand how they can be used to promote desirable behaviors among clinicians.

So, public lashings for having blood stream infections, ventilator-associated pneumonia and similar complications are not sensible. Relying on them simply reinforces the God complex in medicine and punishes the wrong link in the chain of events.

In general, it is time to let what we are learning in behavioral and cognitive sciences about what makes us tick help effect good behaviors at the bedside (and in the executive suite).