Public Performance Reports and the Will for Change
Authors: Donald M. Berwick
Journal: JAMA (2002)

STUDENTS OF IMPROVEMENT IN COMPLEX, HUMAN SYStems have mixed feelings about public report cards on performance. Here is the problem: On the one hand, all improvement is change, and human systems resist change. Therefore, improvement requires a source of tension, discomfort with the status quo, sufficient to overcome this inertia. Sometimes a charismatic leader or a call upon ambition is enough, but usually not. In the commercial world, conventional wisdom holds that “burning platforms” or “threats to survival” are necessary to build will for improvement. On the other hand, not all changes are improvements. To make a complex system better requires learning and local experiments, best of all involving all workers, inviting them to use their knowledge and skills to learn together. As educators know, people do not learn especially well when they are afraid. For health care to improve, learning must occur in teams and across traditional boundaries, and under these conditions fear is even more toxic. Leaders of improvement therefore have a balancing act: to clarify threats enough to make it clear that the status quo is a poor option, and yet to foster the safety, curiosity, and joy in work that make learning possible. Since fear is so abundant in health care, and since “joy in work” seems in especially short supply, the health care improvement movement has tended to emphasize the need for safety and security among workers and to downplay the role of public pressure for change. The article by McCormick and colleagues in this issue of THE JOURNAL recalibrates this balance. It shows that health maintenance organizations (HMOs) that choose voluntarily to release their Health Plan Employer Data and Information Set (HEDIS) score profiles from the National Committee for Quality Assurance in one year are much less likely to choose to release their profiles in the subsequent year if their initial scores fall into the lowest tertile of performance. The correlation is large—in 1999 almost a 6-fold difference in likelihood to withhold subsequent profiles comparing the top with the bottom tertile—and it is clinically significant, since some of the HEDIS indicators involved are associated with important mortality risks. The article by McCormick et al is limited in that it omits some important dimensions of quality of care from its purview. In particular, it does not deal with measures of patient experience and satisfaction, service characteristics like waiting times, issues of equity and management of diversity, or with measures of cost and efficiency. Nor does it attempt to analyze the various uses of HEDIS reporting inside organizations, as distinct from public uses. Moreover, the article does not reveal how many of the organizations that withdrew from voluntary reporting nonetheless have mounted aggressive improvement programs internally using the same information and will emerge in years ahead as success stories for change. Yet the basic finding is strong: the poorer its performance, the less likely an HMO is to admit it publicly. It is not hard to imagine why. Maybe issues of cost, accuracy, or fairness lead HMO leaders to keep their data private. But those hypotheses seem naive. The more likely reason for the biased withdrawal of the poorer performers is that they are being, in the short term, logical. Why, given the option not to invite troublesome scrutiny, should they? Why should any leaders voluntarily reveal their own organization’s deficiencies to outsiders? More interesting might be the reasons that the poorer performers who continue to choose voluntary, public reporting do so. Are they arsonists trying to use HEDIS scores as the burning platform they need to prod their organizations toward change? Do they feel some sort of ethical duty to disclose? Or do they believe that willingness to disclose will earn them more trust and support from the public than secrecy would? McCormick and colleagues are less concerned about the reasons for selective reporting than about the consequences. If performance reporting remains voluntary, they claim, the value of reporting, itself, decreases. Biased dropout rates among poorer performers falsely inflate the apparent performance of the HMO industry as a whole and deny consumers reliable bases for comparison among health plans. The authors declare voluntary public disclosure of HEDIS indicators to be a failure and call forcefully for mandatory performance reports.