Kirschner Kirsten, Braspenning Jozé, Jacobs J E Annelies, Grol Richard
Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, The Netherlands.
Aust J Prim Health. 2013;19(2):102-6. doi: 10.1071/PY12032.
The involvement of target users in the design choices of a pay-for-performance program may enhance its impact, but little is known about the views of participants in these programs. To explore general practices' experiences with pay-for-performance in primary care we conducted a qualitative study in general practices in the Netherlands. Thirty out of 65 general practices participating in a pay-for-performance program, stratified for bonus, were invited for a semistructured interview on feasibility, feedback and the bonus, spending of the bonus, unintended consequences, and future developments. Content analysis was used to process the resulting transcripts. We included 29 practices. The feasibility of the pay-for-performance program was questioned due to the substantial time investment. The feedback on clinical care, practice management and patient experience was mostly discussed in the team, and used for improvement plans, but was also qualified as annoying for one GP and for another GP it brought feelings of insecurity. Most practices considered the bonus a stimulus to improve quality of care, in addition to compensation for their effort and time invested. Distinctive performance features were not displayed, for instance, on a website. The bonus was mainly spent on new equipment or team building. Practices referred to gaming and focusing on those aspects that were incentivised ('tunnel vision') as unintended consequences. Future developments should be directed to absolute thresholds, new indicators to keep the process going, and an independent audit. Linking a part of the bonus to innovation was also suggested. The participants thought the pay-for-performance program was a labour-intensive positive breakthrough to stimulate quality improvement, but warned of unintended consequences of the program and the sustainability of the indicator set.
目标用户参与绩效薪酬计划的设计选择可能会增强其影响，但对于这些计划参与者的看法却知之甚少。为了探究基层医疗中绩效薪酬的一般实践经验，我们在荷兰的基层医疗机构中开展了一项定性研究。在参与绩效薪酬计划的65家基层医疗机构中，按照奖金分层抽取了30家，邀请其就可行性、反馈与奖金、奖金支出、意外后果及未来发展进行半结构化访谈。采用内容分析法处理所得的访谈记录。我们纳入了29家机构。由于大量的时间投入，绩效薪酬计划的可行性受到质疑。关于临床护理、实践管理和患者体验的反馈大多在团队中进行讨论，并用于改进计划，但也有一位全科医生认为这种反馈很烦人，另一位全科医生则表示它带来了不安全感。大多数机构认为奖金除了是对他们付出的努力和投入的时间的补偿外，还是提高医疗质量的一种激励。例如，在网站上并未展示独特的绩效特征。奖金主要用于购置新设备或团队建设。机构提到博弈行为以及专注于那些受到激励的方面（“隧道视野”）是意外后果。未来的发展应朝着设定绝对阈值、制定新指标以推动该过程持续进行以及进行独立审计的方向。也有人建议将一部分奖金与创新挂钩。参与者认为绩效薪酬计划是刺激质量改进的一项劳动密集型的积极突破，但同时也警告了该计划的意外后果以及指标体系的可持续性。
