Impact of economic incentives on quality of professional life

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Impact of economic incentives on quality of professional life
Health Policy 80 (2007) 2–10
Impact of economic incentives on quality of professional
life and on end-user satisfaction in primary care
Joan Gené-Badia a,b,∗ , Georgia Escaramis-Babiano c , Mireia Sans-Corrales d ,
Laura Sampietro-Colom e , Françoise Aguado-Menguy f ,
Carmen Cabezas-Peña g , Pedro Gallo de Puelles h
a
Consorci d’Atenció Primària de Salut de l’Eixample (CAPSE), Spain
b Departament de Medicina, Universitat de Barcelona, Spain
c Departament de Salut Pública, Unitat de Bioestadı́stica, Universitat de Barcelona, Spain
d Castelldefels Health Centre, Institut Català de la Salut, Spain
e Strategic Planning Unit, Catalan Department of Health, Spain
f Evaluation Unit, Institut Català de la Salut, Spain
g Research Unit of the Institut Català de la Salut and the Fundació Jordi Gol i Gurina, Spain
h Universitat Internacional de Catalunya, Spain
Abstract
Background: A new economic incentive scheme based on (i) quality of care objectives for physicians, and (ii) professional
development for both physicians and nurses, was introduced in primary care teams.
Objective: To assess weather the implementation of these economic incentive schemes has had an impact on the quality of
professional life (QPL) of both physicians and nurses and on end-user satisfaction.
Methods: Before–after study. Participants are 257 primary care teams in Catalonia, Spain, in the period 2002–2003. QPL and
end-user satisfaction were used as outcome measures.
Results: QPL was improved in terms of the dimension “perception of support from the management structure” among physicians (4.897 versus 5.220; p < 0.001) as well as nurses (5.272 versus 5.638; p < 0.001). Further, physicians perceived an
increase in the dimension “demands made upon them” (6.124 versus 6.364; p < 0.001), differently from the nurses group
(5.8191 versus 5.929; p = 0.063). Overall, user satisfaction did not vary significantly, although a positive relationship was found
between “perception of support from the management structure” and user satisfaction among nurses (β = 0.078, p = 0.007),
and a negative relationship between “demands made upon them” and user satisfaction in the case of physicians (β = −0.057,
p = 0.011).
Conclusions: Incentives related to quality of care annual targets may increase physicians’ perception of burden and it may have
a negative impact on consumer satisfaction. Incentives on long-term professional development seem to be related to an increase
∗ Corresponding author at: Consorci d’Atenció Primaria de Salut de l’Eixample (CAPSE), C/Roselló 161, 08036 Barcelona, Spain.
Tel.: +34 93 227 98 55; fax: +34 93 227 98 05.
E-mail address: [email protected] (J. Gené-Badia).
0168-8510/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2006.02.008
J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
3
in professionals’ perception of support from the management structure. Among nurses, this increase is related to an improvement
of user satisfaction.
© 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Quality of professional life; User satisfaction; Target payment; Professional development; Remuneration of doctors
1. Introduction
To date, interventions that aimed at improving the
quality of clinical-care provided in primary care settings have not targeted individual health-care professionals. Interventions have largely relied on rather comprehensive strategies, including national clinical practice guidelines, national clinical management standards
for common health problems, the use of new technologies for a better management of information among
professionals, and fostering professional involvement
in the management of health-care services [1]. Thereafter, health-care providers have frequently linked specific remuneration schemes to such dimensions. Further, there is evidence that physicians are likely to
change their practice in the presence of adequate economic incentives [2]. However, there is a debate on the
need of implementing target payment schemes [3], not
only on ethical grounds [4], but largely because of the
limited evidence on its effects. We are uncertain such a
policy will improve the quality of health-care delivered
or, on the contrary, it will lead to skewing clinical activity towards other activities of rather limited health gain
[5–9]. It is also unknown its likely effect on user satisfaction and on quality of professional life (QPL). Such
schemes have also been hypothesized as one of the reasons for growing professional burn-out syndrome [10].
The Catalan Institute of Health (CIH) is the largest
public health-care provider in Catalonia (NE Spain),
offers primary health-care services to 80% of the population in the region (6.5 million persons) and manages
eight hospital centres, largely teaching hospitals. In
2003, the CIH launched a management by objectives
policy together with a specific program to improve
quality standards in the provision of health-care. A
variable payment scheme was introduced among physicians based on their level of achievement of annually
set objectives [11]. In addition, a second group of economic incentives was introduced for both physicians
and nurses who voluntarily enter a brand new professional competence development program, named
professional development scheme. Such program ran
on the basis of long term indicators of clinical competence, professional commitment to CIH initiatives,
individual continuing training, teaching activities and
research outputs [12,13]. This paper examines to what
degree both groups of measures have impacted user
satisfaction with the delivery of care as well as professional quality of life (PQL) in primary care.
2. Methodology
The two groups of economic incentives described
in detail below were implemented in 257 Primary Care
Teams (PCT) summing up 3439 physicians and 3781
nurses.
2.1. Target payment
General CIH strategic objectives were fixed by toplevel managers. Following a cascade process, objectives and targets were set at all sublevels in the organisation involving the adequate intermediate managers at
each stage. As a result, every primary care professional
agreed with the organisation as to which were the adequate annual objectives and targets to be met. These
objectives and targets covered the following key areas:
accessibility to care, quality of clinical care provided,
user satisfaction, standards in drug prescription, management of sick-leave in the population, and PCT budget execution. Economic incentives were set according
to the degree of accomplishment of targets in each key
area up to a maximum – per annum – of 5200D per
physician and 6200D per PCT manager. A part of PCT
managers incentives were linked to the improvement
of professional quality of life (QPL) in their own team.
2.2. Professional development scheme
Simultaneously, a professional development
scheme was introduced based on professional clinical
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J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
competence enhancement, commitment to CIH
initiatives, individual continuing training, teaching
activities and research outputs. Professionals could
voluntary submit applications to an independent
commission and merits on these areas were assessed
over a seven year period. Positive assessments implied
an additional annual increase in individual salaries of
3000D (physicians) and 1400D (nurses).
2.3. Outcome measures
QPL was assessed using a validated questionnaire
[14] administered to all CIH primary care professionals
in November 2002 and 2003. This QPL questionnaire
consists of 34 variables grouped in three-dimensions:
demands of the job, support from the management
structure and intrinsic motivation. A final question
measures the perception of overall quality of professional life. Each item of the questionnaire is measured
on a scale of 1 (none) to10 (a lot).
End-user satisfaction was measured by a validated
questionnaire [15] in a sample of 200 users per PCT
administered from the 3rd to the 7th of both June 2002
and 2003. Failures to respond were covered by substitution. The set of dimensions studied included satisfaction with the care provided by physicians, nurses, and
non-health personnel, satisfaction with the organisation of services, and satisfaction with the quality of the
premises and facilities. Each item was measured in a
scale of 0 (very unsatisfactory) to 10 (very satisfactory).
An additional variable was calculated, namely “overall satisfaction”, using a logistic regression with six
independent variables. The dependant dychotonomous
variable used in the logistic regression was the level of
satisfaction as contained in the statement “yes, I would
recommend” or “no, I would not recommend” this particular PCT to a friend or relative. Quotas were used to
reach a total of 200 users/patients per team, of which
50 were users of paediatric services, 150 (50% female)
were users of primary care physicians services, 2/3 of
them between 15 and 64 years of age, and 1/3 of them
>64 years of age.
Both QPL and user-satisfaction questionnaires were
voluntary and self-administered. Anonymity was guaranteed and the data were confidential. In both questionnaires the unit of analysis was the PCT, using the
mean values of the answers to questionnaires of every
team.
2.4. Statistical analysis
The variables are described by their means and
standard deviations. The differences pre- and postimplementation of the new remuneration schemes on
QPL were compared using the Student t-test for paired
data. To investigate weather these new schemes may
indirectly affect end-user satisfaction bivariate analysis were first conducted comparing pre- and postimplementation using the Student t-test for paired
data, and assessing relationships between user satisfaction and QPL using the Pearson correlation coefficient. Other more complex relationships, such as
quadratic or exponential, were also assessed but the
adjusted R-squared indicated that linear relations even
weak seemed to fit best. Furthermore, a multivariate
regression model with user satisfaction as the outcome variable, including gender, period (pre- and postimplementation) and professional quality of life effects
was carried out. To control the dependencies among
responses induced by the fact that each PCT appears
twice (pre- and post-implementation), a covariance
pattern between observations occurring on the same
PCT was specified within the total variance matrix
[16].
An alpha risk of 5% was assumed. SPSS (version
11.5) package and the PROC MIXED procedure from
SAS (version 9) were used for statistical analysis.
3. Results
Responses rates to the QPL questionnaire was
61.06% in 2002 and 66.68% in 2003.
Tables 1 and 2 show physician and nurses’ perceptions of QPL before and after the introduction of economical incentives. In both physicians and nurses an
improvement was observed in the dimension “perceptions of support form their management structure”. The
overall improved score on this dimension came particularly from a major degree of satisfaction with the salary,
a wider perception of promotion opportunities, and a
greater support from higher levels in the management
structure. In addition, physicians reported feedback on
their work was improved, they felt a greater support
from their team colleagues, and they could now have
more opportunities to express their opinions and needs.
Differently, nurses highlighted there were more oppor-
J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
5
Table 1
Physicans’ quality of professional life (QPL) scores according to dimensions in 257 PCTs
Scores (mean ± S.D.)
Year 2002
p-value
Year 2003
Management structure support
P3. Satisfaction with salary
P4. Promotion possibilities
P5. My competences are valued
P10. Support from my superiors
P11. Support form my colleagues
P14. I can be creative in my job
P16. I get feedback
P20. My opinions are listened
P22. My employees addresses the issue of QPL
P23. My personal autonomy is respected
P28. I can perform a wide range of tasks
P30. My proposals are taken into account
4.897
4.331
3.123
4.023
5.185
6.565
4.738
4.789
5.679
3.735
6.045
5.882
4.861
±
±
±
±
±
±
±
±
±
±
±
±
±
0.764
1.007
0.870
1.082
1.456
1.193
1.115
1.210
1.152
1.144
1.178
0.985
1.140
5.220
4.920
3.623
4.330
5.993
6.785
4.759
5.415
5.930
4.113
5.897
5.955
4.912
±
±
±
±
±
±
±
±
±
±
±
±
±
0.654
0.946
0.971
0.943
1.249
1.065
0.988
1.034
1.047
0.947
0.908
0.899
0.991
<0.001
<0.001
<0.001
<0.001
<0.001
0.006
0.809
<0.001
0.002
<0.001
0.072
0.301
0.522
Demands
P1. Work load
P6. Pressure to comply with the load of work
P7. Pressure to maintain the quality of my work
P8. Rush and strain because of lack of time to do the job properly
P15. I leave job problems at work
P17. Conflict with other team members
P18. My job takes time away from my personal life
P19. Physical discomfort at work
P21. High burden of job responsibility
P24. I am interrupted during my job
P25. Stress
P33. My job affects negatively my health and well being
6.124
8.270
6.799
6.197
7.324
6.295
3.108
5.076
4.563
8.266
5.944
7.060
4.699
±
±
±
±
±
±
±
±
±
±
±
±
±
0.704
0.662
1.102
1.086
1.292
1.116
1.004
1.173
1.402
0.678
1.276
1.129
1.198
6.364
8.404
7.013
6.715
7.662
6.461
3.025
5.210
4.896
8.346
6.318
7.368
5.208
±
±
±
±
±
±
±
±
±
±
±
±
±
0.594
0.656
0.976
1.006
1.128
0.950
0.821
0.943
1.339
0.609
1.113
0.947
1.003
<0.001
0.003
0.005
<0.001
0.001
0.038
0.232
0.109
0.001
0.118
<0.001
<0.001
<0.001
Intrinsic motivation
P2. Satisfaction with my job
P9. Motivation
P12. Support from family
P13. Willingness to be creative
P26. Self confidence in professional competences
P27. I perform adequately in my job
P29. My work has a positive impact in other people health
P31. It is clear what I have to do
P32. I am proud of my job
P35. I have the support of my team
7.619
6.667
7.302
8.310
7.373
7.899
8.192
8.321
7.071
7.421
6.619
±
±
±
±
±
±
±
±
±
±
±
0.498
0.942
0.980
0.807
0.902
0.585
0.530
0.691
0.895
0.900
1.685
7.640
6.665
7.374
8.509
7.370
7.924
8.200
8.357
7.048
7.391
6.833
±
±
±
±
±
±
±
±
±
±
±
0.448
0.857
0.776
0.719
0.785
0.551
0.504
0.588
0.862
0.772
1.685
0.563
0.968
0.326
<0.001
0.971
0.596
0.833
0.496
0.745
0.643
0.255
P34. Overall quality of life
5.258 ± 1.031
5.243 ± 0.861
0.825
tunities to be creative in their jobs, and that they have
gained autonomy in decision-making. In both groups
the perception was that their employer had clearly
addressed the issue of QPL with specific policies and
programs.
As regards the “demand” dimension, only physicians expressed a perception of increased demand on
them, and they argue that not only the quantity of work
has grown but also the pressure to keep up quality. Similarly, they perceived a greater stress as a result of lack
of time to do their job properly, increased physical discomfort at work, too many interruptions and disruption
of work, and the feeling that their job was negatively
affecting their health and well being. On the contrary,
nurses did not find any of these items had increased
significantly.
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J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
Table 2
Nurses’ quality of professional life (QPL) scores according to dimensions in 257 PCTs
Mean ± S.D.
Year 2002
p-value
Year 2003
Management structure support
P3. Satisfaction with salary
P4. Promotion possibilities
P5. My competences are valued
P10. Support from my superiors
P11. Support form my colleagues
P14. I can be creative in my job
P16. I get feedback
P20. My opinions are listened
P22. My employees addresses the issue of QPL
P23. My personal autonomy is respected
P28. I can perform a wide range of tasks
P30. My proposals are taken into account
5.272
5.128
3.646
4.539
5.783
6.935
5.221
4.656
6.033
3.986
5.890
6.586
5.309
±
±
±
±
±
±
±
±
±
±
±
±
±
0.869
1.322
1.243
1.185
1.446
1.185
1.130
1.445
1.243
1.283
1.194
1.080
1.200
5.638
5.739
4.158
5.009
6.289
6.985
5.586
4.864
6.183
4.570
6.097
6.834
5.464
±
±
±
±
±
±
±
±
±
±
±
±
±
0.716
0.946
1.139
1.083
1.283
1.046
1.034
1.148
1.040
1.102
0.951
0.900
1.027
<0.001
<0.001
<0.001
<0.001
<0.001
0.579
<0.001
0.052
0.127
<0.001
0.027
0.002
0.089
Demands
P1. Work load
P6. Pressure to comply with the load of work
P7. Pressure to maintain the quality of my work
P8. Rush and strain because of lack of time to do the job properly
P15. I leave job problems at work
P17. Conflict with other team members
P18. My job takes time away from my personal life
P19. Physical discomfort at work
P21. High burden of job responsibility
P24. I am interrupted during my job
P25. Stress
P33. My job affects negatively my health and well being
5.819
8.087
6.460
6.262
6.978
6.793
3.233
4.382
4.751
7.495
5.596
6.485
4.570
±
±
±
±
±
±
±
±
±
±
±
±
±
0.781
0.717
1.195
1.207
1.276
1.209
1.246
1.307
1.711
0.908
1.446
1.331
1.338
5.929
8.091
6.495
6.337
7.021
6.837
3.304
4.453
4.970
7.485
5.805
6.663
4.697
±
±
±
±
±
±
±
±
±
±
±
±
±
0.688
0.558
0.973
0.952
0.972
1.055
1.219
1.203
1.588
0.763
1.268
1.106
1.106
0.063
0.943
0.698
0.404
0.621
0.617
0.480
0.475
0.072
0.893
0.045
0.064
0.203
Intrinsic motivation
P2. Satisfaction with my job
P9. Motivation
P12. Support from family
P13. Willingness to be creative
P26. Self confidence in professional competences
P27. I perform adequately in my job
P29. My work has a positive impact in other people health
P31. It is clear what I have to do
P32. I am proud of my job
P35. I have the support of my team
7.771
7.152
7.573
8.235
7.681
7.920
8.313
8.304
6.774
7.691
6.747
±
±
±
±
±
±
±
±
±
±
±
0.493
0.930
0.863
0.988
0.876
0.713
0.571
0.694
1.097
0.962
1.782
7.803
7.350
7.748
8.352
7.631
7.917
8.312
8.384
6.777
7.840
6.993
±
±
±
±
±
±
±
±
±
±
±
0.476
0.745
0.849
0.823
0.857
0.601
0.497
0.586
1.017
0.766
1.451
0.394
0.004
0.012
0.112
0.487
0.957
0.978
0.131
0.968
0.027
0.216
P34. Overall quality of life
5.793 ± 1.075
5.934 ± 0.930
0.067
Items within the third dimension explored in QPL,
i.e. intrinsic motivation, did not vary significantly
across the study period. Neither physicians nor nurses
found their intrinsic motivation had been changed
as a result of the introduction of targets and professional developments schemes. Further, the overall
perception of QPL remained moderately high in both
groups.
Regarding end-user satisfaction, only one item in
one of the dimensions explored, namely “cleanliness
of the premises”, improved its score significantly from
one year survey to the other (see Table 3 for details).
Table 4 shows bivariate relationships between user
satisfaction and QPL. In both periods studied, there is
a positive relationship between overall physician and
nurses perceptions on their QPL and overall patient sat-
J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
7
Table 3
User satisfaction questionnaire scores according to relevant dimensions in 257 PCTs
Scores (mean ± S.D.)
Year 2002
p-value
Year 2003
Organisation
P1. Organisation of services
P2. Appointments
P3. General information
P4. Response to phone calls
7.161
7.121
7.149
7.225
6.706
±
±
±
±
±
0.554
0.637
0.482
0.608
1.266
7.145
7.096
7.106
7.229
6.728
±
±
±
±
±
0.601
0.680
0.561
0.617
1.203
0.501
0.368
0.111
0.869
0.609
Physicians
P5. Quality of care provided
P6. Overall information provided
P7. Interpersonal skills and courtesy
8.227
8.227
8.117
8.341
±
±
±
±
0.408
0.407
0.430
0.408
8.231
8.222
8.124
8.339
±
±
±
±
0.412
0.412
0.426
0.410
0.865
0.840
0.777
0.911
Nurses
P5. Quality of care provided
P6. Overall information provided
P7. Interpersonal skills and courtesy
8.068
8.096
8.007
8.104
±
±
±
±
0.462
0.465
0.466
0.468
8.079
8.094
8.018
8.119
±
±
±
±
0.447
0.452
0.457
0.443
0.614
0.955
0.629
0.526
Support personnel
P5. Quality of the service provided
P6. Overall information provided
P7. Interpersonal skills and courtesy
7.231
7.454
7.419
7.431
±
±
±
±
0.532
0.676
0.690
0.705
7.254
7.474
7.434
7.440
±
±
±
±
0.774
0.648
0.659
0.675
0.450
0.461
0.619
0.751
Health-care
P14. Perception of met need
P15. Problem resolution
P16. Professional competence
P17. Primary care-specialist care coordination
P18. Management of urgent demands
P19. Privacy
7.487
7.253
7.218
7.718
7.247
7.396
8.113
±
±
±
±
±
±
±
0.561
0.640
0.628
0.546
0.562
0.687
0.437
7.473
7.222
7.204
7.713
7.221
7.386
8.116
±
±
±
±
±
±
±
0.567
0.650
0.617
0.552
0.606
0.688
0.444
0.576
0.244
0.595
0.852
0.358
0.737
0.904
Premises and facilities
P20. Sense of comfort
P21. Cleanliness
P22. Overall satisfaction with the PCT
7.482
7.064
7.909
7.531
±
±
±
±
0.741
0.891
0.646
0.563
7.559
7.125
7.994
7.544
±
±
±
±
0.854
1.085
0.682
0.595
0.101
0.342
0.031
0.615
Overall satisfaction
7.320 ± 0.534
7.329 ± 0.542
0.726
Table 4
Relationships between user satisfaction and QPL
Year 2002
Physicians
QPL dimensions
ρ Pearson
p-value
ρ Pearson
p-value
Management structure support
Demands
Intrinsic motivation
0.122
−0.368
0.002
0.375
0.081
<0.001
0.973
<0.001
0.107
−0.335
0.029
0.344
0.086
<0.001
0.641
<0.001
Management structure support
Demands
Intrinsic motivation
0.110
−0.203
−0.003
0.203
0.117
0.004
0.970
0.004
0.110
−0.220
−0.074
0.185
0.077
<0.001
0.234
0.003
P34. Overall quality-of-life
Nurses
QPL dimensions
P34. Overall quality-of-life
Year 2003
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Table 5
Effects on user satisfaction obtained from the multivariate regression analysis in 257 PCTs
Gender (Men)
Physicians demands
Nurses management structure support
Point estimate
Standard error
p-value
0.088
−0.057
0.078
0.017
0.022
0.029
<0.001
0.011
0.007
isfaction with services and care provided. However, a
negative relationship was found between patient satisfaction and workload (demand) imposed on both physicians and nurses in period studied.
Finally, Table 5 shows adjusted effects on user
satisfaction according to the multivariate analysis.
As deduced from the model, no significant changes
were found on overall user satisfaction between preand post-new schemes implementation. It was found,
though, that among respondents, men scored higher
levels of satisfaction than women. Physicians increasing demands impact negatively on user satisfaction
while nurses’ perception of management structure support impact reversed. No other statistically significant
changes were observed for other dimension in the QPL
questionnaire.
4. Discussion
The results show there is a relationship between the
implementation of economical incentives, and changes
in the QPL of health personnel and end-user satisfaction. The observed improvements in the “perception
of support from the management structure” among
physicians as well as nurses may be related to the economic incentives to professional development since
both groups benefited from such a scheme. Among
nurses, this improvement is related to an increase
in end-user satisfaction. Physicians, differently than
nurses, reported an increase in the burden of the
demands. This may come as a consequence of economic incentives being related to quality of care targets
since only physicians received it. The increase in physicians’ perception of burden of the demand is related to
a negative impact on consumer satisfaction.
While nurses enjoy a linear payment model and felt
neither increased pressure nor stress in their job conditions, physicians’ perceived a greater pressure on their
jobs possibly as a direct effect of the introduction of target payment schemes linked to annual objectives. This
additional pressure may aggravate the burnt-out syndrome identified among health-care professionals in
previous unpublished CIH surveys. Another study carried out in Spain shows that emotional fatigue directly
correlates with the perception of demands and inversely
with the overall QPL [17]. Accordingly, we would
argue against setting physicians’ targets too aggressively. Targets should ideally be agreed with professionals in a top-down and bottom-up approach that
could ultimately reflect their capabilities and means.
Nurses did not show a decrease in their QPL score.
This is important insofar it could be argued it has a
direct effect on physicians’ perception of support from
their team members, which in turn is necessary to the
achievement of targets set at team level.
This study reports the impact of these measures
on end-user satisfaction is very low. In this sense, we
should argue that, once a high level of satisfaction is
reached (as measured by patient interview surveys) it
becomes difficult to achieve a major positive change
or improvement. Further, it is difficult to disentangle
which variables have a major impact on user satisfaction. User satisfaction could be affected by quite
a number of factors, which barely depend on healthcare professionals’ performance [18]. Looking into the
future definition of objectives for target payments we
would recommend the use of indirect indicators of satisfaction, which could be more effectively influenced
by physicians and the nurses’ performance (e.g. time
per consultation, or appointments cancelled by the professional) rather than end-user interviews surveys.
Along with other authors [19–22] we have shown
that the overall perception of QPL among physicians
and nurses correlated positively with the user satisfaction.
Despite target payment schemes have increased the
perception of the demands made upon physicians; they
have not significantly modified the overall satisfaction
among users seeking care. This may be as a result of
a mixed effect of the economic incentives on professionals’ QPL. The negative impact on user satisfaction
J. Gené-Badia et al. / Health Policy 80 (2007) 2–10
due to the burden of demand perceived by physicians
has been balanced by the positive effect of the nurses’
improvement on the “perception of support from the
management structure”. Another plausible explanation
to this could be found in the fact that the disclosed
increased demands have been moderate. This reinforces our argument against the use of more aggressive
targets and objectives, which could eventually result
in a greater perceived burden ultimately affecting user
satisfaction [23–25] and quality of the clinical-care provided [24].
The promotion of quality of care is a strategic element in both target payment and professional development schemes. This is of utmost importance particularly at the CIH in which professionals are largely
civil servant workers who, traditionally, have had little incentives coming from the organisation itself to
improve quality of care, and no penalties are applied
to the delivery of poor quality of care. These schemes
have further used concepts that have been easily understood by health-care professionals moving away from
a predominant bureaucratic jargon.
The study design does not allow us to conclude
there is a causal relationship between the measures
implemented and its outcome. We cannot deny that
other management initiatives such as clinical governance [12], or the afore-mentioned improvement in
some health centre premises, might have influenced
the results. Further, the design does not make use of
a control group. In fact, very few studies do in this
case and, when available, there is little scientific evidence on management improvements. In this sense, the
study design reflects real management conditions and
this fact imposes a series of limitations that should be
acknowledged.
Despite gender is a condition that influences the perception of QPL [26], available data does not allow for
a gender analysis in our case. This variable was not
recorded in questionnaires so as to preserve anonymity
of data in small health centres. However, it should be
noted that the vast majority of nurses are women and
they also represent the 54% of physicians of primary
care personnel in Catalonia.
Another limitation of this paper is the fact that the
time period considered could be judged as too short.
Our purpose was to disclose the available evidence
as soon as it became available. We encourage, however, a longer time reference for future analysis. In
9
this respect, we are unsure whether physicians’ perception of increased support from the management
structure will remain high over a longer period and
whether the perception of higher health-care demands
and requirements will be increased over time. The disclosed positive impact is probably a consequence of its
innovative nature in a bureaucratic culture of management.
As a conclusion, we could argue that while incentives related to achievement of annual health-care quality targets might increase physicians’ perception of the
burden of the demands, albeit within tolerable limits,
incentives on long term professional development seem
to be related to an increase in the professionals’ perception of support from the management structure. We
encourage further research and analysis into professional incentives impact on relevant outcome measures
before spreading such reforms to a broad amount of
professionals. Results from this study encourage us to
think of professional remuneration schemes as promising tool for changing professional beliefs and modifying users’ satisfaction. Finally, a longer period of
analysis is encouraged together with a broader set of
outcome measures.
Acknowledgements
The authors would like to thank all the health-care
professionals and users of primary care at the CIH
who collaborated in the administration, collection and
response to the questionnaires used in this study. This
research has been partly funded by the Instituto de
Salud Carlos III (FIS #PI021762). Additional financial assistance was provided by the Fundació Jordi Gol
i Gurina, which took care of translation and manuscript
preparation expenses. The authors would like to make
explicit there has been no conflict of interest in any
respect.
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