SECRETS OF THE CMO: PERSPECTIVES AND SUCCESS
The phrase “you can’t manage what you can’t measure” is often attributed to W. Edwards Deming, the statistician and quality-control expert credited with having launched the Total Quality Management (TQM) movement; at other times, it is attributed to Peter Drucker, one of the world’s most renowned management consultants.(1)
But both men were too sophisticated to have said something so reductionist. One of the “seven deadly diseases” of management that Deming himself warned against was business management based on numbers alone.
Physician executives play a delicate and contradictory role in healthcare organizations. In addition to following the Hippocratic Oath of Care, they must drive key performance measures for the organization, such as readmissions, patient satisfaction, and efficiency. They also must maintain the trust and morale of medical personnel, whose autonomy and patient-centered focus are essential to providing excellent care. These competing interests can result in dilemmas, such as when organizational objectives come in conflict with the aim of patient-centered care.
Several well-known economic and social theories — Goodhart’s Law, surrogation, Campbell’s Law, and the Cobra Effect — can help us examine the difficulty of this balancing attempt. Such concepts explain how decisions can be driven by performance metrics and have unintended consequences that skew the very things they are supposed to accomplish. Physician leaders need to understand and apply these principles and models because they must strike a balance among business goals, medical ethics, and patient safety.
THE DANGERS OF PLACING TOO MUCH FOCUS ON METRICS
Economist Charles Goodhart wrote, “when a measure becomes a target, it ceases to be a good measure.”(2) This principle, known as Goodhart’s Law, highlights the drawbacks of relying too much on specific metrics to gauge performance.
When an organization targets one measure, such as decreasing hospital readmissions, it could encourage behaviors that prioritize that goal over other less concrete ones. It can have unexpected medical implications.
Think about a hospital system where a target number of daily patient consultations is used to gauge physician performance. If doctors are under pressure to see more patients, then the increase in volume may come at the expense of quality or patient experience. Doctors may feel pressured to expedite appointments, sacrificing thoroughness for expediency. These imbalances could lead to unnecessary treatments or inadequate care.
Speaking of patient satisfaction, these scores are frequently used to assess hospital quality and physician performance. Even though patient satisfaction is a crucial component of care, focusing too much on these indicators may lead to procedures that prioritize patient preferences above professional judgment.
To get a higher satisfaction rating, doctors may practice in a way that does not align with evidence-based medical advice. Less successful outcomes — namely, missing diagnoses or inadequate patient education — may arise as a result.
A measure may be gamed or controlled when it becomes a target, which can have unanticipated results. This is a challenge for medical executives who need to combine performance goals while upholding high standards of patient care.
THE DANGER OF USING METRICS IN PLACE OF REAL RESULTS
This substitution of a desired outcome with a more easily quantifiable target is called surrogation. This happens in the healthcare system when agencies or physicians focus on easy-to-measure metrics that lack the breadth required to describe the experience of care.
Over time, these placeholder metrics can distort healthcare’s true purpose, which is the enhancement of patient health and well-being. But they are helpful for keeping track of general patterns.
Clinical compliance as a measure of quality care is a form of medical surrogacy. Hospitals could, for example, track how many patients with chronic conditions, such as diabetes, are being checked or prescribed medications regularly. Though these initiatives could lead to healthier lives, they do not consider every person’s particular needs and interests.
A physician might prescribe a medication according to a rule, but even if the drug doesn’t work for the patient’s unique circumstances, that act is a “success.”
An overemphasis on throughput metrics, such as lower ED wait times or more patients seen each day, is another instance of surrogation. Those statistics can fail to reflect the quality of care received at those visits, even if they appear to indicate the level of healthcare delivery. To achieve these aims, physicians might rush through patient appointments, which could compromise quality.
While goals are important, physician executives must be mindful to focus on improving patients’ lives and health.
THE UNINTENDED CONSEQUENCES OF PERFORMANCE METRICS
Donald T. Campbell’s observation, often referred to as Campbell’s Law, reminds us that “the more a quantitative social indicator becomes employed for social decision-making, the more vulnerable it will be to manipulation pressures and the more likely it will be to distort the social processes it is designed to monitor.”(3) This insight is relevant in healthcare, where performance metrics are a cornerstone of operational and clinical decision-making.
Striving to meet performance benchmarks, such as reducing the length of stay or reducing readmissions, may cause unintended consequences. For example, some systems might inadvertently incentivize early patient discharges or selective admissions, potentially leading to compromises in patient care.
While these practices may align with financial goals or compliance requirements, they highlight the tension between accountability and the commitment to delivering the best possible care.
Healthcare would do well to remain vigilant about the potential for performance metrics to shape behavior in unintended ways. By encouraging a culture of transparency, accountability, safety, and ethical decision-making, we can align organizational goals with the mission of patient-centered care.
Encouraging clinicians to consider patient needs while being mindful of metrics can ensure that performance measurements enhance rather than detract from the quality and integrity of care delivery.
Through thoughtful implementation and regular evaluation of performance metrics, healthcare institutions can strike the right balance, using data to improve outcomes without compromising the trust and well-being of the patients we serve.
THE COBRA EFFECT: WHEN REWARDS DON’T WORK
The Cobra Effect describes the unexpected outcome when an incentive designed to solve a problem worsens it. The name comes from British colonial India.(4) The state sought to regulate snakes by paying for every cobra killed. The bounty encouraged people to grow cobras so they could kill them and get the reward, thus not limiting the number of cobras.
The government realized what was happening and ended the program. When the incentive was removed, the bred cobras were released, and the population boomed to an even higher level.
The Cobra Effect may manifest in the healthcare industry and have unforeseen repercussions. Consider a healthcare organization that incentivizes quick appointment scheduling by rewarding clinics for reducing wait times. While this initiative aims to improve patient access, it might unintentionally encourage clinics to prioritize shorter, less complex cases over patients with chronic or complicated conditions who may require longer visits. As a result, some patients may experience delays in receiving the care they need, counteracting the initiative’s original intent.
The Cobra Effect highlights how important it is to appropriately design performance metrics and incentive schemes to make sure they align with the fundamental goals of patient care. Executives in the medical field need to be aware of the unintended consequences of incentives, especially those that emphasize short-term over long-term goals. Quality, patient-centered care should be encouraged via a well-balanced incentive structure.
PHYSICIAN EXECUTIVES’ CRITICAL ROLE
Physician executives are crucial in resolving the moral conundrums brought on by the need to prioritize patient care while meeting metrics and objectives. Medical executives must make sure that their companies employ performance metrics that accurately reflect patient outcomes rather than proxies or targets subject to manipulation.
One crucial strategy is to shift the focus from volume-based to quality-based metrics that reflect the important elements of patient care. These include metrics like patient understanding, safety, and health outcomes. Physician executives should work with medical staff to promote a culture that prioritizes patient-centered care.
As they attempt to navigate between the conflicting pressures of achieving organizational goals and putting patient care first, physician administrators encounter difficult ethical conundrums. Comprehending theories such as Campbell’s Law, Goodhart’s Law, surrogation, and the Cobra Effect can assist physician executives in understanding the unexpected consequences of relying too much on performance metrics. The goal is to align metrics with actual patient outcomes rather than indicators that don’t fairly represent quality care given.
Physician executives should foster an environment of openness, responsibility, and patient-centered care to maintain the confidence of their medical staff and uphold their moral obligation to put patients’ needs first.
References
Hunter J. Myth: If You Can’t Measure It, You Can’t Manage It. The W. Edwards Deming Institute. August 13, 2015. https://deming.org/myth-if-you-cant-measure-it-you-cant-manage-it/ .
Goodhart C. Problems of Monetary Management: The UK Experience. In: Monetary Theory and Practice. London: Palgrave; 1984. https://doi.org/10.1007/978-1-349-17295-5_4 .
Campbell DT. Assessing the Impact of Planned Social Change. Evaluation and Program Planning. 1979;2(1):67–90. https://doi.org/10.1016/0149-7189(79)90048-X
Dubner SJ. The Cobra Effect: A New Freakonomics Radio Podcast. Freakonomics, LLC, October 11, 2012.