Table 3.

Summary of sites’ mental models and degree of positivity, intensity, and consistency

Performance category (2007–2008)	Site	Performance category (2011–2012)	Mental model summary	Sign/theme	Intensity	Consistency
High performers	B	Moderate	Aim: EPRP feedback is communicated, tracked, and improved upon in a ubiquitous, transparent, non-punitive, systematic, and consistent way.	Positive: transparency	Medium	High
	H	High	EPRP as a benchmark or model for the best standards of care for keeping the whole patient as healthy as possible.	Positive: benchmarking	Medium	Low
	M	Moderately high	EPRP measures are generally OK, but not sophisticated enough to be reflect actual care quality	Negative: EPRP not a good representation of quality	Medium	High
Consistently moderate	D	Moderate	EPRP serves as a primary means of linking the work/efforts of all facility staff to the facility’s mission: to provide the best quality of care that veterans expect and deserve	Positive: strategic alignment	Medium	Medium
	K	Moderate	EPRP is not a real true reflection of the quality of one’s practice because of the sample size at a particular time period.	Negative: EPRP not a good representation of quality	Medium	Medium
	E	Moderately high	Clinicians think EPRP is inferior to their population-based, VISN created dashboard, and leaders have concerns about overuse and misinterpretations or misuse of EPRP	Negative: EPRP not a good representation of quality	Medium	Medium
Highly variable	A	Low	EPRP remains relevant as a starting point for setting, aligning, and monitoring clinical performance goals	Positive: strategic alignment	Medium	High
	G	Moderately low	EPRP as an “outside checks and balance” system that validates whether or not how the facility thinks they are doing (e.g., good job) and what challenge areas they have are accurate, however, there are no real or punitive consequences to scoring low.	Mixed	Medium	Medium
	L	Low	Although EPRP does not reflect actual care quality, the numbers indicate that they are doing something consistently right that helps their patients	Mixed	Low	High
Low performers	F	Moderate	Immediate feedback is advantageous to memory, but not always well received.	Negative: EPRP has made us hyper-vigilant	High	Medium
	C	Low	EPRP is viewed by some as an objective, unbiased measure with some sampling limitations; by others, EPRP is viewed as inaccurate or retrospective	Negative: EPRP not a good representation of quality	Medium	Low
	J	Low	Site struggles to provide feedback; clinicians did not receive EPRP and PMs until the PACT implementation.	No feedback until PACT	Low	Medium

Note: 2012 performance categories differ from 2008 because 2012 performance forms a continuum rather than discreet categories (see Fig. 1 and main text for details)