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As your urgent care center grows or volumes increase one of the challenges that often faces the owner is: How to incentivize urgent care practitioners to perform better. In other words, how can you as the owner encourage your physicians to improve their documentation, dispense from your in-house formulary or perhaps even just pick up the pace in order to increase patient flow?

The most common answer for many operators is to offer some sort of bonus structure or Pay for Performance (P4P) in addition to the practitioner base salary. Based on a variety of measurable factors such as productivity, coding, or revenue, these P4P schemes have been commonplace in many health systems for years and are even resurfacing as a hallmark of Accountable Care Organizations (ACO’s) in an effort to help reduce readmissions and over-utilization.

In urgent care, bonus structures or similar P4P have likewise been implemented to promote adherence to proper documentation, utilization of in-house pharmacy, and patient satisfaction. But in general, most practitioner bonus structures are more of an effort to reward good work rather than tool to alter behavior.
Perhaps this is a smart approach? Consider for a moment a recent study conducted by Dr. David Himmelstein, professor at the City University at New York’s School of Public Health. Dr. Himmelstein found that overly prescriptive financial P4P contracts may lead to practitioners feeling as though they have lost the motivation to do what’s best for the patient, instead engaged in gaming “ or teaching to the test.
He found in systems that extensively promote P4P or other forms of bonus structures, practitioners were often more focused on the rules or statistics being measured rather than the outcomes of the patients under their care. Ultimately, one would think that optimal outcomes would be the goal, but in the age of cutting costs and enhancing revenues, all-too-often the paradigm shift seems to be less patient-centered and more about efficiencies with dollar signs attached.

Other similar studies concur with Dr. Himmelstein’s opinion finding when reward based incentives are used to guide performance often the results are counter-productive. While the output for some tasks might increase, often times motivation is weakened and performance on tasks that require highly cognitive function (such as medical care) generally declines. Dan Ariely, James B. Duke Professor of Psychology and Behavioral Economics at Duke University, stated in his book about reward “based performance, that the unintended consequence is likely a worsening of care, not its improvement.”

So where does this leave you “ the owner of the urgent care who’s simply trying to reward his staff while promoting certain behaviors that ultimately will benefit the function of your clinic while enhancing the experience of your patients? On one hand, many practitioners have come to expect bonus structures for performance, but on the other, shouldn’t employees just be expected to do a good job?

It’s a tough predicament, especially when you’re faced with trying to increase patient transit times in the clinic or encourage your providers to document visits more thoroughly. But if Dr. Himmelstein’s research is correct, then the motivation to perform is more intrinsic and less monetary. To do otherwise will only weaken overall care and create an environment where staff performs to a minimum requirement needed to achieve the reward.

And perhaps this makes sense; after all, do you really want an employee who performs better only when you PAY them to do so?

So then, if P4P schemes aren’t the way to go, what can you offer practitioners on your staff as an incentive to perform better or to increase certain markers such as patient satisfaction?

Maybe the answer is simple- Begin with clear expectations of performance. Creating a wage that compensates for that expected performance does not need a bonus dedicated to going above and beyond since the practitioner would already be meeting the expected level. Providing ongoing training and feedback also helps staff know when they are meeting expectations of the job. Far too often, many operators never meet with their staff until they have some axe to grind about the employee’s work. By then, the work habits are ingrained or the behaviors seemingly accepted by management and no amount of reinforcement (positive or negative) will have long term affect.

And lastly, know when to throw in the towel with a poorly performing employee. Most will agree that even with P4P schemes, the employee that simply has no desire to adhere to the organizations guidelines for quality will not be motivated by any amount of bonus money. Identify these employee’s early on and don’t be afraid to encourage them to find other career paths outside your urgent care.

Rewarding employees for good work is still a GREAT thing to do. Just make sure that you aren’t falsely creating rewards for work that should be an expected part of the employee’s job. Poor staff will never follow no matter how big of a carrot you dangle in front of them and great staff will eagerly go above and beyond because they are inspired or impassioned to do so. What are you incentivizing for in your practice?

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