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A process for objective review of physician performance.

How do you objectively evaluate physicians at reappointment. How do you establish a common ground for the evaluation process that still acknowledges acceptable differences in performance? Perhaps one physician has some difficulty with documentation and attendance at meetings, but has no quality problems clinically. Another physician may have good documentation and meeting attendance, but has some quality problems. Another physician has a behavior pattern that is disruptive, a few documentation problems, but excellent quality. Yet another physician is a marginal practitioner with major problems in several areas, including quality. Reappointment of these physicians might be extremely difficult, especially if the credentials committee is recently appointed and not familiar with the details of the performance data.

The Credentials and Executive Committee at Guernsey Memorial Hospital, Cambridge, Ohio, faced with the difficulties of evaluating the performance of a wide variety of physician practice styles and technical competence, developed a more objective means of tracking physician performance. Previously, physician data accumulated over a two-year period was listed on a reappointment sheet. Many of these data had not been directly evaluated by the existing Medical Staff Executive Committee or Credentials Committee. The Committee often floundered in attempting to determine the significance of data presented at the time of reappointment. In an effort to create a more objective means of tracking physician performance and hence provide a more objective evaluation at the time of reappointment, a point system similar to that used by peer review systems was developed.

With this system, data are collected from all available sources of physician performance; any variances that are identified through any of the mechanisms of quality assurance, peer review, PRO inquiries, malpractice suits, patient complaints, and clinical pertinence are assigned points. Also included are other areas affecting physician performance, such as meeting attendance, disruptive behavior, etc. (figure 1, page 52). The data are funneled back to individual grids for each physician that are reviewed concurrently, periodically, and at reappointment time. Trending for improvement or deterioration of a physician's performance can be readily seen by reviewing this grid sheet at any time (figure 2, page 53).

Most of the peer review quality variances are assigned levels (0 through IV in figure 1. Five levels were necessary to properly evaluate the different clinical variances. For example, physician #007 may have a problem with history and physical examination documentation and on clinical pertinence review was found to have omitted the ENT, neurology, and rectal exams--for this, 0.5 point might be assigned. On another chart, physician #007 is found to have been delinquent with a history and physical examination for which a Level I quality severity (one point) would be assigned. then mortality review revealed a quality problem that was assigned to Level II (five points). Figure 3, page 53, shows how these points for physician #007 would accumulate on the physician graphic sheet, which is available for a quick review of the physician's performance.

The final determination and assignment of points is completed by the Medical Staff Executive Committee. In larger hospitals, this could be done at the level of the various departments or services and forwarded to the Medical Staff Executive Committee. Physicians are notified each time the final assignment of points are made by the Medical Executive Committee. The peer review paper trail is tracked by use of a worksheet (figure 4, page 54) so that each variance is treated in the same manner for each physician and charts are not inadvertently lost to follow-up. Any communication with the attending physician and with the service or department chiefs is recorded and placed in the physician's Q.A. file. (Because of a July 1, 1990 change in the JCAHO recommendation, peer review may be done outside the Medical Staff meeting or department level except for generic reporting, so these communications may be kept in a separate file.

The point assignments for clinical pertinence and disruptive behavior are also outlined in figure 1. If these are significant variances, they will affect patient care and can then be treated with the quality severity levels. Risk management points (figure 1) would be utilized with events such as jousting in the medical record between physicians, the physician and the hospital, physicians and the federal government, etc.

All quality assignments of Level II or greater are automatically given additional review either in-house (if the medical staff is large enough) or outside (if there is any question of antitrust implications). Certain levels of points automatically trigger review by the Medical Staff Executive Committee. A total of 20 points was selected for immediate Medical Executive Committee review, because, if the evaluation raises quality issues, there would be significant adverse affects on patient care. If the evaluation raises a combination of quality and other problems, it is probably of a significant magnitude to at least require surveillance by the Executive Committee. Point total accumulation and recommended actions are shown at the bottom of figure 1. For more than 10 points, in-house education is suggested. Generally, this involves a one-on-one discussion with the physician at the level of the Department Chairperson or the Medical Director (or both).

For more than 15 points, intensified review is recommended; if it involves quality issues, a percentage of charts are then reviewed, perhaps even a 100 percent review for a prescribed period. For a total of more than 20 points, immediate review by the Medical Executive Committee is suggested; generally at this point, the recommendation would be for some sort of formal continuing medical education or evidence of prescribed self-study. A total of more than 25 points would require some additional Medical Executive Committee action. A level IV quality severity issue would give rise to an immediate 25 point accumulation. This should translate into immediate Medical Executive Committee action.

If more than 30 points are accumulated within any 12-month period, concurrent review on all admissions is suggested. If more than 40 points are accumulated within a 12-month period, consultation on all admissions would be recommended. Usually point totals of this magnitude would be composed of quality problems. If the totals were accumulated from other sources, these would have to be addressed in a different manner, with appropriate Medical Executive Committee action according to the medical staff bylaws.

At the level of 50 points accumulation within a 12-month period, a consideration of restricted privileges is entertained. Usually a definite trend would be established by this time and patient safety would probably be endangered.

Restricted reappointment should be entertained with the accumulation of 75 points or more, for that point total might constitute three Level IV quality problems or a considerable number of lesser quality violations that would most likely establish a trend.

This system was established and given a six-month trial period at our institution. At the end of this time, it was found to be working satisfactorily. With the system in place, the Medical Executive Committee found it necessary to evaluate more closely quality issues that were referred out of the various departments. They were also forced to make a descriptive decision on the quality issue by establishing one of the five levels of quality problems. Additionally, the system seemed to eliminate some of the "good old boy" decisions of the past that had a tendency to leave the final evaluation of the quality problem "up in the air" at the time of reappointment. At the end of the trial period, several of the point assignments were changed to further refine the process.

Our institution now has had almost three years' experience with the system, and the Medical Executive Committee finds it extremely helpful in streamlining the reappointment process. When the Medical Executive Committee reevaluated the plan after the initial six-month trial period and decided to continue it, the plan was presented in detail to the medical staff at department levels, and all questions were answered in detail. Even after this presentation, a small number of physicians found it very difficult to accept the assignment of any points. It was explained that, with the scope of the system, it would be difficult for a practitioner not to have at least a fraction of a point or a point at some time. It was stressed that this was meant to be an objective system for evaluation and education, not a punitive one. It was also explained that the one-on-one discussions and continuing medical education were an integral part of the process. If this system is adopted, the medical staff should be very thoroughly acquainted with it and the educational aspects should be stressed and presented in a positive manner. Even after thorough discussions of the system with the medical staff, be prepared for some unusual responses from a few members.

The point values assigned may vary from medical staff to medical staff according to needs. If emphasis is believed to be necessary in certain areas, the point values may be raised by the Medical Staff Executive Committee. This would have the same effect as lowering thresholds to improve quality or performance. The weighting of the points for each area of performance, or the total accumulation of points, can be adjusted to complement the individual medical staff's needs. As performance improves, the weighting can be changed to enhance the overall quality of the group. This has the advantage of permitting the various committees or departments to translate performance to a common denominator that can then be evaluated objectively. Further refinements by certain groups or specialties would be optional.

With small modifications, this system should adapt easily to physician practice and managed care organizations where physician performance requires evaluation. Additional point levels could be developed for physician productivity and patient satisfaction.
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Title Annotation:Credentialing and Privileging
Author:Haun, John P.
Publication:Physician Executive
Date:May 1, 1992
Previous Article:Physician perspectives on the structure and function of group practice HMOs.
Next Article:Planning for change.

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