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Commentary |

Aligning Rewards With Large-Scale Improvement

Keith Evan Mandel, MD
JAMA. 2010;303(7):663-664. doi:10.1001/jama.2010.156.
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Intensified health care reform efforts increase the urgency to achieve significant improvements in quality and substantial cost savings at the national level. Yet the pace of executing and spreading effective improvement interventions makes it unlikely these outcomes will be achieved in the foreseeable future. Although frameworks for large-scale improvement have been described by the Institute of Medicine, Commonwealth Fund, and others, there is limited evidence about how to design and implement system changes that improve population-based quality measures while also overcoming challenges inherent to large-scale change. Even though there is increasing evidence from innovation networks, improvement collaboratives, and national improvement campaigns about what works, the likelihood of achieving regional, state, or national-level improvement goals is limited without disruptive strategies that accelerate large-scale diffusion of effective interventions.13 Shifting the focus to rewarding sites (eg, primary care practices, hospitals) based on first achieving population-based improvement goals represents a disruptive innovation with significant potential to accelerate the spread of evidence-based interventions, thus maximizing the effects on quality and costs at a national level.

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Figure. Conceptual Model for Rewarding Large-Scale Improvement
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The site-level eligibility criteria represent measurable behaviors that support achieving aggregate-level performance goals. The site-level performance targets are based on thresholds set higher than aggregate-level targets to reward outstanding performance.
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