• Laura J Damschroder, Claire H Robinson, Joseph Francis, Douglas R Bentley, Sarah L Krein, Ann-Marie Rosland, Timothy P Hofer, and Eve A Kerr.
• VA Center for Clinical Management Research, Ann Arbor, MI, USA, Laura.damschroder@va.gov.
• J Gen Intern Med. 2014 Dec 1; 29 Suppl 4: 877-84.

BackgroundClinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement.ObjectiveOur aim was to understand how the implementation of diabetes performance measures (PMs) influences management actions and day-to-day clinical practice.DesignThis is a mixed methods study design based on quantitative administrative data to select study facilities and quantitative data from semi-structured interviews.ParticipantsSixty-two network-level and facility-level executives, managers, front-line providers and staff participated in the study.ApproachQualitative content analyses were guided by a team-based consensus approach using verbatim interview transcripts. A published interpretive motivation theory framework is used to describe potential contributions of local implementation strategies to unintended consequences of PMs.Key ResultsImplementation strategies used by management affect providers' response to PMs, which in turn potentially undermines provision of high-quality patient-centered care. These include: 1) feedback reports to providers that are dissociated from a realistic capability to address performance gaps; 2) evaluative criteria set by managers that are at odds with patient-centered care; and 3) pressure created by managers' narrow focus on gaps in PMs that is viewed as more punitive than motivating.ConclusionsNext steps include working with VHA leaders to develop and test implementation approaches to help ensure that the next generation of PMs motivate truly patient-centered care and are clinically meaningful.

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