How Hospitals Responded To A Financial Incentive To Improve Quality: A Qualitative Analysis Of The French Hospital Pay-For-Performance Experiment (IFAQ)

International audienceObjectives: The aim of this study was to assess the impact of financial incentives on hospitals based on the perspectives of professionals working in the hospitals. Pay-for-performance (P4P) programs have been used extensively in modern health systems but there is little evidence that these programs may improve quality of care. Methods: The study was conducted using a qualitative approach based on data derived from four distinct hospitals involved in IFAQ, the first P4P program for hospitals in France, which started in July 2012 and will end in June 2014. The study looked at 222 voluntary acute care hospitals and its aim was to test the impact of a financial incentive on quality improvement. The four hospitals were selected according to the size, the status (profit, non-profit), the ownership (public, private), the university affiliation, and the location, to ensure adequate representation. The analysis consisted of 30 semi-structured interviews with the hospital staff (directors, heads of department, and the frontline staff including physicians, nurses and assistants), conducted between April and September 2013. The interview guide was shaped by a literature review and validated by experts in the field. The main parts consisted of:1. participants awareness and understanding of the experiment,2. the perceived validity and feasibility of the program,3. the Organisational culture of their Organisation,4. their opinion on the financial incentive (size, distribution),5. the corrective actions to be taken. Interviews lasted about one hour each and were then recorded, transcribed and Analysed by classifying data into categories, and reviewing internal documents for external validity. Results: The study explored the different views of participants within the enrolled hospitals. The findings indicated that major gaps existed in participants’ attitudes, mainly due to the lack of information given to them. Knowledge about the P4P experiment was limited to the administrative level and therefore did not percolate within the Organisation. A typology of the different perceptions was constructed to Analyse how the experiment was apprehended within the hospital. First, top-management believed quality-based payments were critical in the present context and wanted their hospitals to be pioneers. They also perceived P4P as an opportunity to advocate the importance of quality within the hospital, and the experiment as a way to better engage practitioners in quality improvement programs. In contrast, frontline staff, including physicians, nurses, and assistants were mostly unaware that money was tied to the results of a set of quality indicators. During the interviews, physicians were mostly neutral about the experiment, mainly because they thought IFAQ would not impact the Organisation of their work. On the other hand, nurses and assistants, whose work can be affected by this financial incentive because of the selection of process indicators, which must be documented on a daily basis, were uninformed about this program. In addition, the frontline staff expressed concern of becoming overburdened by administrative tasks. Finally, very few actions were undertaken during the first year of the experiment. The fact that the model was still under construction at that time was one of the main explanations provided. Conclusion: Today, minor changes could be observed among enrolled hospitals. Since adherence of professionals is needed to maximize the program effectiveness, a questionnaire-based study (222 hospitals, June 2014), based on these results, will be conducted to better understand how they perceived IFAQ to adjust the program, if needed