EDITORIAL

Assessing physician performance and learning needs in primary care in Portugal - Beyond SIADAP

John Yaphe*

*Associate Professor, Community Health, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence

---

 

Health systems require performance assessment to promote quality improvement. Bold steps taken by the Portuguese National Health Service may ensure that qualified professionals give excellent service to satisfied patients at a reasonable cost. While the NHS bears some responsibility for this, professional commitment to life-long learning begins in medical school and must be reinforced in vocational training.

Health care reform in Portugal includes assessment of performance indicators at the clinic level. Although the recent economic crisis has stalled the payment of bonuses for achievement of health targets (in Model B Family Health Units with a pay-for-performance scheme), contracts based on indicators have changed primary care in Portugal.

How has this improved the performance of doctors? Individual efforts are blurred in the mass of data collected at the health unit or regional level.

The Integrated System of Management and Evaluation of Performance in the Public Service, known as SIADAP (Sistema Integrado de Gestão e Avaliação do Desempenho na Administração Pública), is designed to assess the performance of individual employees.¹ The law dates from 2007 (amended in 2010 and 2012) and was intended to replace the old system of promotion by seniority, by agreement between the doctors’ unions and the government.

This evoked harsh criticism in the popular press and private conversations and met with resistance in sectors like education. Fears of Big Brother and the use of assess-ment findings in disciplinary actions were raised.

Medicine has been slow to apply SIADAP. We have recently seen the creation of mechanisms to allow the implementation of individual performance assessment in health care.

In theory, the law is a good one. True feedback can be a gift. Continuous professional development is an obligation of all professionals who strive for excellence. Working with a trained assessor can be effective in assessing practice and developing SMART goals (specific, measurable, achievable, realistic, and time-based) for performance improvement.

The law mandates the assessment of programs, managers, and workers at various intervals. It promotes excellence in care, in a spirit of fairness and transparency. Components of the assessment include personal objectives, behavioural competencies, and professional attitudes through valid and reliable performance measures, with feedback of results and corrective measures to improve performance.

Individual targets might copy those used as clinical indicators. But performance indicators at the health unit level have also had undesirable effects. Targets need to be evidence-based and some fall short. Not everything that is important can be measured and not everything that is measured is important. Some indicators promote medicalization without solid evidence for gains in health (e.g. number of visits during pregnancy, proportion of patients on a doctor’s list seen in a year, and too tight control of glycosylated hemoglobin).

One way to avoid the shift to “Indicator Based Medicine” and to aim for meaningful outcomes is to allow doctors to set their own performance targets. This is consistent with good adult education. The best learning is self-directed learning. Active learning focused on real needs is the most effective form of continuous professional development.

We need to take into account contextual factors such as prior knowledge of the patient and the type of health problem encountered when assessing communication skills.² A lack of attention to the context of the clinic (urban or rural, rich or poor community) has also been a source of criticism of the current indicators used to assess the quality of practice management.³

Data abstracted from charts can indicate high quality performance by doctors in areas such as cardiovascular risk factor management⁴ and in diabetes care.⁵ However no single source of data is adequate for performance assess-ment.⁶ Chart audits, patient surveys, and administrative data also need to be collected. While the electronic medical record may yield relevant data, patients can tell us about their actual medication use and chronic disease management.

Multi-source feedback involving chart reviews, interviews, patient input, and personal learning plans is a time-consuming process, requiring up to 8 hours per doctor.⁷ Dedicated assessors stimulating reflection and providing feedback and follow-up are needed.

Valuable questions often arise at the point of care in daily practice. The real challenges faced by family doctors in practice could help set standards for performance improvement.^8-9

The current economic crisis threatens assessment because there will be no financial rewards for meeting or exceeding performance targets. On the other hand, there are no penalties either, despite fears of censure. Fortunately, Portuguese family medicine is characterized by a high degree of idealism and dedication.

The lack of valid reliable tools for assessment of professional attitudes also presents a challenge. Judging one’s identification with organizational goals of the SNS, including belief in equity of access to care, may lead to bland declarations of “articles of faith”.

Will assessment be flexible? Many aspects of practice need improvement beyond existing performance indicators. Will personal objectives focus only on targets such as blood pressure or will they take a broader view of professionalism? Participation in activities like clinical research, teaching, and approved educational activities might also be recognized, encouraged and rewarded.

One possible strategy for performance assessment might be to create a contract between family doctors and their peers in the health unit. Each family doctor should be able to design a personal development plan for the following two years, including performance targets and self-directed learning activities based on a combination of audit findings and a learning needs assessment.

We will be watching SIADAP closely to see that it reaches its objectives without unwanted adverse effects. We invite our readers to share in this effort, to study the effects of performance assessment, and to publish their finding with us.

 

REFERENCES

1. Direção-Geral da Administração e do Emprego Público. Sistema integrado de gestão e avaliação do desempenho na administração pública (SIADAP). Lisboa: DGAEP; 2014 (cited 2014 Jun 9). Available from: http://www.dgap.gov.pt/index.cfm?OBJID=83ddd323-6047-46db-b137-6a732c8c2202        [ Links ]

2. Essers G, Kramer A,  Andriesse B, van Weel C, van der Vleuten C, van Dulmen S. Context factors in general practitioner-patient encounters and their impact on assessing communication skills: an exploratory study. BMC Fam Pract. 2013;14:65.         [ Links ]

3. Basto-Pereira M, Furtado SI, Silva RJ, Fachado González F, Vara Fernandes TM, Correia de Sousa J, et al. Performance indicators for clinical practice management in primary care in Portugal: consensus from a Delphi study. Eur J Gen Pract. 2014 May 20:1-6. (Epub ahead of print)        [ Links ]

4. Lipner RS, Weng W, Caverzagie KJ, Hess BJ. Physician performance assessment: prevention of cardiovascular disease. Adv Health Sci Educ Theory Pract. 2013;18(5):1029-45.         [ Links ]

5. Hess BJ, Weng W, Lynn LA, Holmboe ES, Lipner RS. Setting a fair performance standard for physicians’ quality of patient care. J Gen Intern Med. 2011;26(5):467-73.         [ Links ]

6. Green ME, Hogg W, Savage C, Johnston S, Russell G, Jaakkimainen RL, et al. Assessing methods for measurement of clinical outcomes and quality of care in primary care practices. BMC Health Serv Res. 2012;12:214.         [ Links ]

7. Overeem K, Lombrats MJ, Arah OA, Klazinga NS, Grol RP, Wollersheim HC. Three methods of multi-source feedback compared: a plea for narrative comments and coworkers’ perspectives. Med Teach. 2010;32(2):141-7.         [ Links ]

8. Bjerre LM, Paterson NR, McGowan J, Hogg W, Campbell CM, Viner G, et al. What do primary care practitioners want to know? A content analysis of questions asked at the point of care. J Contin Educ Health Prof. 2013;33(4):224-34.         [ Links ]

9. Ebell MH, Cervero R, Joaquin E. Questions asked by physicians as the basis for continuing education needs assessment. J Contin Educ Health Prof. 2011;31(1):3-14.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

None stated.