PART I: We don’t have to incentivize humanity

THE PRESSURE TO PERFORM

By Victoria Sale and Ellen Schultz

In this article, Part 1 of 2, co-author Victoria Sale draws on her personal experience as a nurse and teacher to illustrate the perverse ways that performance measurement, when implemented within the social sector, often works against the very people it is intended to benefit.  In Part 2, we examine the broader impact of performance measurement in the social sector and explore how to redesign measurement through shared power.

“She’s in the emergency room again? I’m completely out of ideas to help her - I shouldn’t be doing this job anymore. She deserves a better nurse case manager than me.” Those were the thoughts running through my head as I sat, flushed with humiliation, sure that my colleagues in the emergency department (ED) were staring at me. I’d just logged on and seen that, once again, Angie had been to the ED last night.

Angie is not her real name, of course. Her name, her struggles, her story are not for me to tell. The tension on this day was recognizing that I was under pressure to reduce ED use for the patients I supported as a nurse case manager within an intensive care management program, and despite following a detailed checklist of medical and social follow ups, Angie’s “unnecessary utilization” remained unchanged.

This focus on measuring performance was not unique to my situation. Like most hospitals and healthcare systems across the country, our program and organizational success was largely based on our ability to reduce ED and overnight hospital visits. It was how we received the green light for more funding to expand and serve more people, and to keep the lights on. 

As a nurse case manager, when Angie kept returning to the ED, I didn’t just feel like I was letting her down. I felt like I was letting the organization down, and jeopardizing future funding for the whole program. The pressure to make Angie “perform” well by reducing her ED use was so persistent that although I’d developed deep affection for Angie and her family, when it came time to report outcomes, I flashed to visions of how I would defend myself in front of my peers at case conference. I dreaded the questions about whether it was worth continuing to see Angie, because she wasn’t “making any progress.” I found myself being aloof, not looking up from my clipboard, staying focused on my task list rather than on Angie herself. But underneath that aloofness was my own fear and desperation to change her “performance” so I could keep seeing her.

The tension of needing to make other human beings “perform for the system” was not new to me. Before becoming a nurse, I taught high school science. In just a few years of teaching I had already come to understand a predictable pattern of what happens when we shift accountability for performance outcomes with deeply systemic social roots onto frontline workers like teachers, nurses, and doctors. I saw clearly that dangling carrots, rewarding “top performers,” and shaming people does not work. I learned that applying narrowly-focused performance-driven incentives to human services systems such as healthcare and education makes them behave in predictable, counter-productive ways. This pattern is characterized by paternalistic behaviors, a transactional focus on tasks rather than building trust, and redirecting resources away from those who do not perform to system-defined standards. 

Denied Support

Performance measurement has been in use in U.S. public education for decades. It reached its most recent peak with the No Child Left Behind (NCLB) legislation of 2002 that sought to incentivize K-12 public schools to better educate students by instituting increasing levels of penalties for schools that did not meet state-specific measures of student achievement. These measures focused on reading, writing, math skills, and levels of physical fitness. While the more recent Every Student Success Act of 2015 moderates some of those penalties, the focus on standardized testing as a key measure of school and educator performance remains across the U.S. public education system.

In practice, the humanness of childhood and family life often conflict with this drive for performance. Charlie shows up to “Writer’s workshop” hungry because his father lost his job. Marcia’s mother died unexpectedly in a car accident, and she cries during math. Nicole has a crush on her female biology lab partner and spends the year questioning her identity. Faced with penalties for under-performing on standardized tests, instead of supporting students and families in navigating this complexity, schools bring in more reading experts and implement mandatory scripted math curriculums. The idiosyncratic, messy, but essential process of guiding and caring for students too often falls by the wayside in pursuit of efficiency, standardization, and fidelity to mandated curricula. 

Rather than reaching out and offering additional support to the people who most need it, experienced frontline workers learn to avert their eyes from students, patients, and clients who aren’t “performing.” Performance measures incentivize focusing on people who most readily improve performance in the short-term, particularly in response to standardized, top-down improvement strategies. This often redirects attention and resources away from those who most need sustained support from a trusted service provider. 

One moment with Angie stands out in my memory. I was checking in with her at home, checklist in hand, ready to tackle the next round of appointments and service coordination. But instead of running down my to-do list, I put aside my clipboard full of metrics and checkboxes and sat down next to her on the porch. I told her I could see she was still in pain – pain that goes deeper than physical ailments. I asked: Do you want help with that other pain? It was then Angie told me about the roots of her pain and her struggles, roots buried deep in childhood trauma. I held her hand and cried with her as she told her story. 

Angie was eventually dropped from the intensive care management program, denied continued support because she was not making progress in the way the program measured success. Angie was also discharged by the case management programs from all her other healthcare providers. While never explicitly stated, I believe a core reason for her discharge was because she “ruined outcomes averages,” threatening program funding, future grant opportunities, and organizational performance. 

We Don’t Have to Incentivize Humanity

Angie continued to go to the ED regularly throughout the time I worked with her. I could not show measurable improvement in her outcomes in any of the ways my organization or its funders wanted to see. But I did make a difference. Years after I’d moved on to a new role and she had moved to a new city, she called me. To check up on me, she said. She wanted to tell me she was doing OK. By then I was not seeing patients anymore, was no longer facing quarterly reports of ED visits or medication adherence or time between hospital stays. I did not ask Angie about her health, or medications, or appointments. I did not even ask her what “doing ok” meant to her. If she felt she was doing ok, isn’t that all that matters? I talked with Angie about her family, her life. I thanked her for calling. 

My humanness mattered to Angie in ways our measures of performance never captured. Experience shows that despite largely efficiency-driven incentives, front-line workers in jobs of caring will find ways to steal moments for humanness even amid a relentless drive for performance. Teachers call parents after school because they sense something is troubling a student. Primary care doctors call patients to answer questions about test results, even after a 12-hour shift. In hospitals across the country nurses used their personal cell phones to help patients who were severely ill with COVID-19 FaceTime with loved ones. No one gets paid any extra for this. These are good people who are doing their best to bring humanity into poorly designed systems. 

There’s no performance measure that can capture what it meant in that moment to know that Angie cared enough about me to call years later and check in. Her rate of ED visits may not have changed in the time I worked with her, but I knew that I had made a difference in her life. And she made a difference in mine. 

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Acknowledgements:

We are grateful to Rachel Davis, Rebecca Sax, and Gwynn Sullivan, and for making time to review and critique an earlier version of this article. We also thank Jason Turi for introducing us to one another - your spark lit a fire for us both.

*Shout out Wylly Suhendra for taking the the beautiful cover photo found on Unsplash here. Attribution is important.