Anesthesia Service Incentives, Metrics, and Surrogate Indicators
saying in business that “you get the behavior you measure.” But what if you measure the wrong stuff? Anesthesia services are constantly the victims of perverse incentives, vanity metrics and faulty surrogate indicators. The reports that anesthesia services generate, and the behavior that these reports engender, are an ever-present diversion from improvement in anesthesia services.
If the goal of an anesthesia service is to do things faster, better, and cheaper, then the incentives that make our processes worse are truly perverse. If the cost of measurement is greater than the cost of improvement, how does this make business sense? A recent blog post mentions that the Medicare Physician Reporting System (“PQRS”) bonus system in 2012, 2013, and 2014 “hardly seems worth the effort.” More important, there is the law of unintended consequences. What if an incentive in one area actually causes harm greater harm to the larger organization? What is the return on investment (“ROI”) of our improvement efforts? We recently did a study where the well-intended effort for greater accuracy in anesthesia service pharmacy changes had a clearly negative ROI for the organization. A “penny wise, pound foolish” approach may have the unintended consequence of limiting staff acceptance of future, and possibly better formulated, initiatives.
Vanity metrics can be equally diversionary. There is a wealth of research information on operating room and anesthesia service operations, but proprietary analytical packages provided by anesthesia consultants and experts (“ACEs”), anesthesia management companies (“AMCs”), and/or physician practice management companies (“PPMCs”) may provide pretty looking “feel good” results. This information looks good in PowerPoint, but it may not result in actionable metrics. What looks good in a sales pitch may not be better for a facility. The devil is in the details and details of a proprietary analytical package need to be carefully studied.
As management of anesthesia service gets more distant from the clinical site, there is a natural tendency to develop reports to demonstrate to a distant hierarchy that things are actually being done faster, better, and cheaper. These reports often include the use of surrogate indicators. What if the indicators are faulty and they actually engenders activities that are not faster, better, and cheaper? It is important to differentiate between the following:
- Financial and operational driven management indicators
- Clinical indicators for clinicians
- Performance indicators focusing results
- Risk indicators focusing on the causes of adverse outcomes
Incentives, metrics, and surrogate indicators may or may not provide useful information. In reality an anesthesia service is intense exercise in human resource management. Data analysis must be used carefully to provide improvement of an anesthesia service. By its very nature data is the history of the anesthesia service. To manage an anesthesia service from distance based on historical data is like driving a car looking through the rear view window. The future of an anesthesia group is determined by putting the right people in the right places.
Take Home Points:
- Beware of what you ask for, for you may get it