Background

Performance measurement (PM) and management for quality have become ubiquitous in 21st-century healthcare. Numerous entities have independently developed measures for assessing mortality, quality of chronic-disease care, access and patient satisfaction. Consequently, measures have mushroomed; for example, the National Clearinghouse for Quality Measures houses nearly 1100 active measures.1 Despite this proliferation, those whose performance is being measured have had little input in measure development. Research consistently shows when performance measurement systems are implemented by leadership divorced of the evidence-based motivational component that induces goal commitment and facilitates behaviour change, these do not accelerate performance improvement.2 3

For example, traditional PM systems like the Healthcare Effectiveness Data and Information Set have focused on disease prevalence yet lack a conceptual model of the clinical-performance criterion domain. Outside of healthcare, performance measurement systems such as Total Quality Management (TQM), Lean/Six Sigma and Balanced Scorecards are based on conceptual models about the nature of quality and performance, yet lack bottom-up motivational features, leading to mixed success and sustainability.3 4 For example, TQM and Lean methods assume that people inherently want to contribute to quality, though quality must be driven by committed senior leaders responsible for quality.5 However, psychological research indicates goal-directed behaviour change is strongest when people are committed to their goals.6 Thus, TQM and other systems often lack the motivational component that facilitates the transition from receiving performance information to inducing desired behaviour change. Indeed, recent research suggests systems such as Lean have had mixed success and long-term sustainability.2 3

For example, although increases in productivity and reduction of waste (a signature outcome of Lean) associated with using Lean Six Sigma have been well documented in healthcare, implementation and sustainment has been challenging due to tensions between “the need to demonstrate efficiency and achieve performance targets… and the …