Performance management and audit & feedback to support learning and innovation: Theoretical review and implications for Swedish primary care

Health care professionals frequently describe performance management and monitoring of efficiency and quality measures for external accountability as an administrative burden with limited benefits. Professionals argue that they are subject to too tight control that signals distrust, limits professional autonomy and ultimately decreases their motivation to perform. At worst, poorly incentivized indicators influence the behavior of providers in directions that undermine patient benefits. Against this background, policy interest has recently turned towards new governance and managerial approaches in Swedish health care services, allowing for a higher degree of professional autonomy, participatory processes and use of non-financial incentives. This change will undoubtedly have implications for performance management. Inspired by current changes in Swedish primary care, this article explores the design of audit & feedback elements through a review of the empirical evidence and theories about motivation and incentives. Audit & feedback interventions have so far taken a “diffusion of innovation” perspective focusing on implementation of evidence and targets into practice. More complex changes in the delivery of services is likely to require experience-based DUI (Doing, Using, Interacting) modes of innovation, which in turn calls for a more formative and enabling approach to performance management and audit & feedback. A key question is how an appeal to social determinants of professional identity and reputation mechanisms can motivate professionals to change their behavior. Practical implications and research opportunities that follow from the theoretical propositions are discussed using Swedish primary care as an illustrative case.