Newtown, CT – April 10, 2015
What does it take to motivate a high performer to continue a high level of performance? In the 1960s, Frederick Herzberg published what became the most widely read paper in the Harvard Business Review and, three years ago, we dusted it off and explained the importance of Herzberg's findings for the new healthcare environment. A year later, with support from the Robert Wood Johnson Foundation, we published a report on how to improve the design of incentives to free motivation – not just of providers, but consumer-patients as well. Earlier this week, a paper co-authored by Jessica Greene, Judy Hibbard and Valerie Overton, details the results of a multi-year employed physician compensation scheme initiated by Fairview Medical Center. The upshot is that the significant portion of total salary compensation that was linked to quality metrics led to substantial improvement from the lower performing providers, and much less so from the higher performing providers. There's nothing surprising to us here, but everyone should pay attention to the findings, and apply the lessons learned.
What this means to you – The high performers of today became high performers despite a mountain of incentives that pushes them every day towards mediocrity. In other words, they have defied and continue to defy the odds, and it's pretty clear that money has not, and won't, motivate them. Instead, the internal generator that pushes them to the top of their profession is charged by a very different fuel than money. Understanding that charge is the key to motivating them to achieve greater heights and set higher standards for their peers. The lower performers, who had been affected by the mountain of negative incentives, suddenly found themselves freed from those restraints and their performance improved. More than a decade ago we arrived at the same conclusion: the change in incentives simply provides the opportunity to do what's right, professionalism drives the rest. So what happens next? First, the financial reward's initial effect will wear off, and that's ok. Importantly, throwing even more money in the rewards pool won't have much of an effect, because another finding of the study is that the easy harvest of low-hanging improvements is done, and now comes the hard part of more complex care reengineering. Second, the key to motivating the high performers and continuing to move the lower performers up the ladder of high quality care, is to highlight the results of the high performers and encourage them to mentor, teach and lead their colleagues. The next phase of success for Fairview's physicians isn't individual achievement, but collective achievement. Third, the lessons of this salary compensation scheme are applicable to organizational compensation/payment reform. There's a reason why the high performers that rushed into the Medicare payment reform programs are leaving (or have left): they have been and continue to be punished for their high performance, and it's pretty tough to stay motivated when the system punishes you for your good work. Fifty years after Herzberg published his paper, it might be time for health care leaders to read it and understand what motivation is all about.