DDHA 8503 Week 10 Alignment Audit Example

The Plan Says Reachable, Affordable and the Best Place to Practice; the Bonus Pays for Visits: An Alignment Audit of One Primary Care Group's Aims, Measures and Incentives

Student Name

Walden University

DDHA 8503: Strategic Management and Systems Thinking

Instructor Name

Month Day, Year

The Plan Says Reachable, Affordable and the Best Place to Practice; the Bonus Pays for Visits: An Alignment Audit of One Primary Care Group's Aims, Measures and Incentives

Purpose and Method

This audit checks whether the measures Brightwater Medical Group reports and the incentives it pays point where its strategic plan says it is going. Brightwater is a composite fourteen-clinic primary care group, and its aims below are quoted exactly from its published 2025 to 2028 strategic plan, so that the audit compares the organization with its own words rather than with a paraphrase. Measures come from the monthly operations dashboard, incentives from the clinician compensation plan and the departmental budget targets, and routines from the standing agendas of the operations committee and clinic leadership meetings. Every entry in the table can be traced to one of those documents.

The Comparison

Table 1

Stated Aims Against Measures, Incentives and Routines

Aims are quoted from Brightwater's published strategic plan; the remaining columns come from the dashboard, compensation plan, budget targets and meeting agendas.

Following the Sharpest Contradiction

The sharpest contradiction sits in the second row. The plan's commitment to being the best place to practice is measured once a year by survey, while the compensation plan pays every quarter for visit volume. When a clinician faces two signals, the one that arrives more often and carries money usually wins. Brightwater's protected inbox time, introduced six months ago, is counted as clinical time on the schedule but earns no relative value units. A clinician who uses it as intended answers messages for two hours a week and sees about six fewer patients, lowering their bonus. A clinician who books patients into it instead raises their bonus and leaves the inbox for the evening. The data show the second choice is common among clinicians with the largest panels, the same clinicians whose evening inbox time did not fall in the consequence review.

Kerr (1975) described organizations that pay for one behavior while hoping for another, and noted that the hoped-for behavior rarely wins. Here the hoped-for behavior is a sustainable workday, and the paid behavior is volume. The consequence travels through the loop described earlier in the term: evening inbox work sustains burnout, which over time reduces the clinical hours clinicians offer. Shanafelt et al. (2016) found that burnout was followed by reductions in physicians' professional work effort, so the bonus that rewards visit volume today may reduce visit volume in two years.

The Second Contradiction

The third row shows a contradiction between two departments rather than within one. The plan promises affordability. The finance department's budget target counts revenue from billed online visits, and its monthly review asks why the figure is below target. The clinics receive the question, and a few clinic managers have begun reminding clinicians to bill eligible messages. Each billed message adds a charge for a patient, which the plan's affordability aim would discourage. Neither side is acting in bad faith; each is following the signal its own system sends. No meeting brings the two signals together.

The Quiet Contradiction

The fourth row is quieter but telling. Continuity is a stated aim, and its measure is reported, but it appears on no agenda and carries no incentive. The fast lane, introduced to resolve messages that need visits, books the first available clinician, which is usually not the patient's own. The routine that consumes attention, filling fast-lane slots, works against the aim that nobody watches. Kaplan and Norton (1992) argued that measures matter only when they are linked to strategy and actually used to steer decisions; a measure reported and never discussed provides the appearance of attention without its effect.

What Can Be Fixed and What Cannot

Some contradictions can be fixed by changing a measure or incentive. Protected inbox time can be credited with relative value units equivalent to the visits it replaces, which removes the penalty for using it. The fast lane can first offer the patient's own clinician's held slot, with the first available clinician only as a fallback, and continuity can be added to the clinic leadership agenda. These changes cost money or schedule flexibility but do not require Brightwater to want anything different. They should be made first, because they are within management's authority and because their effects will show within a quarter in the early measures the group already tracks. If evening inbox time among large-panel clinicians falls after protected time is credited, the audit's reading of the second row will have been confirmed. If it does not, something other than the bonus is keeping those clinicians in the evening inbox, and the next audit should look for it.

The affordability contradiction is different. Brightwater has to decide whether online visit revenue is a goal or a by-product. If it is a goal, the plan's affordability aim should be rewritten to say which patients will be charged and why. If it is not, the finance target should drop it. That is a choice about what the organization wants, and no change in measurement can make it on the organization's behalf.

References

Kaplan, R. S., & Norton, D. P. (1992). The balanced scorecard: Measures that drive performance. Harvard Business Review, 70(1), 71-79.

Kerr, S. (1975). On the folly of rewarding A, while hoping for B. Academy of Management Journal, 18(4), 769-783. https://doi.org/10.2307/255378

Shanafelt, T. D., Mungo, M., Schmitgen, J., Storz, K. A., Reeves, D., Hayes, S. N., Sloan, J. A., Swensen, S. J., & Buskirk, S. J. (2016). Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clinic Proceedings, 91(4), 422-431. https://doi.org/10.1016/j.mayocp.2016.02.001