Review of: Whyte BS, Ansley R: "Pay for Performance Improves Rural EMS Quality Investment in Prehospital Care." Prehospital Emergency Care. 12(4):495-7, 2008.
This paramedic service in southeastern Minnesota opted to provide monetary incentives for protocol compliance to determine if such incentives would improve compliance. During the study, and previously, they provided routine quality improvement including run review, educational programs and remediation of providers failing to meet specific benchmarks. Dr. Whyte decided to concentrate on the following specific benchmarks and provide the corresponding monetary incentives for compliance:
- Administration of aspirin to all non-traumatic adult chest pain -- $100
- Performance of 12-lead in chest pain -- $100
- Appropriate treatment of traumatic hip pain -- $100
- Documentation of the onset of CVA stroke symptoms -- $100
- Completion of run reports within three hours following the call -- $200
- Chute time of less than 90 seconds -- $400
Post-incentive run reports were completed within three hours 99.7% of the time, with 21 of 24 providers meeting the goal 100% of the time. Before the incentive, reports were completed within three hours 64% of the time, with only two of 23 providers meeting the goal 100% of the time. The out-of-chute goal of less than 90 seconds was met 98.7% of the time, compared with 90.1% before the incentive. Aspirin use in adult non-traumatic chest pain improved from 68% to 96.3%, and electrocardiogram (ECG) performance in this group improved from 43% to 87.8%. Documentation of the time of onset of symptoms in stroke patients improved from 97% to 100%, and the assessment of and intervention for pain in traumatic hip pain patients improved from 56% to 100%.
Dr. Whyte concluded that monetary incentives improved protocol compliance and could be used to improve patient care.
Finally, we're beginning to recognize that EMS is a business. In business, we reward excellence. For too long, we've viewed quality improvement as the stick instead of the carrot. The carrot for most services has simply been a "Job Well Done!" memo or your picture on the Hall of Fame. But in these harsh economic times, memos and pictures don't put food on the table. Recruitment and retention in EMS continues to plague us when the average EMT can make more flipping burgers. And while they're flipping burgers, they're provided monetary incentives for customer satisfaction. So why not do the same in EMS?
Should this pay-for-performance incentive be the norm? I don't know. Even Dr. Whyte argues that the potential for abuse, such as when a medic may be overly aggressive with morphine for the hypotensive hip fracture in pursuit of obtaining the incentive. But before my readers start their flame throwers, let me pull back the curtain on medicine in general. In the ED, I'm paid by performance. If I don't document my care consistently with the level of service, then the billing company can't bill appropriately and I suffer a negative monetary incentive. If my hospital doesn't meet state and federal benchmarks in quality, we risk the loss of Medicare funding.
Creating an environment that rewards excellence is preferable to one that concentrates on punishing underperformance. The form of that reward should be consistent with the needs of the employees. If movie tickets or a pizza party will do it; then fine.
As Dr. Whyte explains succinctly in this study, it s vital that the program have close oversight to ensure there are no moral abuses and that the benchmarks being rewarded result in improved patient care and efficient service operation.