Abstract
Background: A growing body of public management literature sheds light on potential shortcomings to quality
improvement (QI) and performance management efforts. These challenges stem from heuristics individuals use when
interpreting data. Evidence from studies of citizens suggests that individuals’ evaluation of data is influenced by the
linguistic framing or context of that information and may bias the way they use such information for decision-making.
This study extends prospect theory into the field of public health QI by utilizing an experimental design to test for
equivalency framing effects on how public health professionals interpret common QI indicators.
Methods: An experimental design utilizing randomly assigned survey vignettes is used to test for the influence of
framing effects in the interpretation of QI data. The web-based survey assigned a national sample of 286 city and county
health officers to a “positive frame” group or a “negative frame” group and measured perceptions of organizational
performance. The majority of respondents self-report as organizational leadership.
Results: Public health managers are indeed susceptible to these framing effects and to a similar degree as citizens.
Specifically, they tend to interpret QI information presented in a “positive frame” as indicating a higher level of
performance as the same underlying data presenting in a “negative frame.” These results are statistically significant and
pass robustness checks when regressed against control variables and alternative sources of information.
Conclusion: This study helps identify potential areas of reform within the reporting aspects of QI systems. Specifically,
there is a need to fully contextualize data when presenting even to subject matter experts to reduce the existence of bias
when making decisions and introduce training in data presentation and basic numeracy prior to fully engaging in QI
initiatives.