| The Physician Leader's Guide
Using Physician Profiles in the Reappointment Process John S. Coldiron, M.D., M.P.H.
All too often, medical staff reappointment tends to be viewed as less important than initial appointment. While the background of new applicants is closely scrutinized, reappointment may be perceived as an administrative routine, not an occasion for thorough reappraisal. In this article, the author argues that objective information about clinical performance, summarized in a readable profile, can be the basis for informed reappointment and privileging decisions.
Medical staff reappointment should be an extremely important element of continuous quality improvement, an opportunity to reaffirm a practitioner’s competence and identify any areas needing improvement. However, according to one study, some 21.3 percent of Joint Commission-surveyed hospitals did not adequately reappraise physicians’ clinical and/or technical skills at the time of reappointment and received a contingency for this reason from 1987 to 1989.(1) Given the limitations of Joint Commission surveys, this figure probably understates the number of hospitals that are not engaging in a thorough reappraisal process. Unless a physician has been involved in a serious quality assurance matter, behavioral problem, or other unusual circumstance, it is likely his or her reappointment file contains little more than a completed reapplication form and routine verifications of licensure, CME, and so forth. This is not much to help a department chair or Credentials Committee asked to make a judgment regarding a practitioner’s continuing clinical competence. And it’s not terribly helpful to the practitioner, either.
The biennial reevaluation of medical staff members’ performance can provide the opportunity for a critical but constructive examination of current clinical and behavioral competence. The department chair can use this occasion to share with the practitioner objective performance information, as well as informal feedback that may be useful to the practitioner in improving his or her practice and relationship to the hospital. Information that compares an individual’s practice characteristics with aggregate information regarding peers can reinforce the practitioner’s understanding of personal strengths and also identify areas for improvement. The reappointment can be future-focused in other ways, too. The chair can discuss the physician’s planned future activity at the hospital and hear any needs or problems that the physician is encountering within the institution that may discourage use of the facility or interfere with optimum patient care. This information can be used as input to improve hospital systems.
The Value of Practice Profiles In the past, it was often assumed that a department chair knew the competence of the other physicians in the department simply by proximity of practice and by passively listening for informal feedback. This subjective approach was prone to serious flaws - often complicated by the politics of proprietary and competitive interests - and is no longer acceptable in any setting.
Physician practice profiles, particularly those that include comparative data, can be very useful in helping physician leaders make informed decision about reappointing staff members and renewing clinical privileges. Practice profiles consist of locally relevant data elements measuring various aspects of a physician’s practice at the institution, including results of peer review. This approach to evaluation of a physician’s practice at the institution, including results of peer review. This approach to evaluation of physician performance, also called practice pattern analysis (PPA), is emerging as an effective method for providing meaningful information to further decision making regarding reappointment. Several variations of PPA, including the use of aggregate data by practitioners, are successfully being used.(2) Almost 60 percent of hospitals surveyed for Hospitals magazine indicate that they currently prepare physician-specific comparative profiles.(3)
Elements of a Physician Profile As a physician leader, you should expect your organization (within its resources) to provide a profile of information that will help you assess the performance of practitioners for whom you must make a recommendation. You, in turn, have a responsibility to:
What should go into a profile? With the help of physician leaders, each institution can develop relevant parameters. In general, a profile may include information in four categories:
The profile is not the only information assembled. The practitioner completes a reapplication form and the appropriate parties verify information on current licensure, liability insurance, National Practitioner Data Bank, health status, etc. The profile adds objective performance information not usually assembled in the past. Before discussing profile use, let’s examine three of the major categories of profile information. (Resource use/cost data are discussed in a separate chapter on economic credentialing.)
Participation In Medical Staff Functions Few physicians enjoy participating in required medical staff functions, but most recognize their importance. One portion of the profile summarizes how well practitioners are fulfilling these responsibilities. Although this is probably the least important aspect of the profile, it cannot be disregarded. The essential community service and quality improvement activities of the medical staff cannot be fulfilled without physician involvement.
Figure 1 lists common medical staff activities. Some are straightforward, such as attendance at department and committee meetings, participation in peer review activities, and (for new members) participation in medical staff orientation. Other activities may include providing care for indigent and uninsured patients, contributing to continuing education activities, and, as appropriate, participating in scholarly activity.
Information on participation in required activities can be summarized in a simple reporting format that reflects the local standards and preferences. For instance, the profile could show meeting attendance in percentages, a total of CME hours, and a list of participation on committees and other activities inside and outside the organization.
Depending upon the value placed upon these activities versus the contribution that the staff member makes through his or her clinical practice, the reviewer must make a judgment as to the relative importance of these activities. An applicant’s failure to meet these obligations may not have any direct impact on the quality of patient care, but it can have a large impact on the fairness of the distribution of required medical staff clinical and administrative activities. Judgments in this regard must be based on policy. The judgment of the reviewer should follow the expectation guidelines set by the medical staff or departmental policy. In the absence of such policy, the reviewer should request guidance from the appropriate departmental or Medical Executive Committee. Otherwise, lack of uniformity of treatment is likely to result among medical staff members and will, sooner or later, cause disharmony.
Characteristics of Clinical Practice Activities The next section of a profile is designed to describe, in numerical terms, the volumes and types of care involved in the physician’s practice. There are no right and wrong numbers here, unless a facility has established minimum activity levels to ensure proficiency for certain procedures or for other reasons.
Comparative data for the various items included under the rubric of clinical activities (see Figure 2) must also be based upon medical staff and departmental standards (e.g., standards for medical record and progress note completion) that are approved, promulgated, and then monitored uniformly with timely feedback. Utilization data can be compared both internally and externally with properly adjusted case mix groupings. Numbers of admissions, procedures, and consultations can be compared intra-institutionally to specialty-specific groups. The concept of “comparative data” will not apply to such items as professional liability cases, however, because the specifics of each situation must be reviewed to determine if a significant pattern exists.
Again, these data can be presented in a simple reporting format that reflects the preferences of the individuals who will be expected to use the data.
Peer Review Results Perhaps the most critical area in terms of quality is analyzing the peer review results that have accrued in the biennium sine the last appointment or reappointment. Typically, this section of the profile includes information obtained from both internal and external formal peer review processes such as traditional quality assurance review activities, utilization review, issues identified through risk management occurrence screening, findings of focus case review, indicator monitoring, and internally confirmed PRO findings.
It is important to remember that the peer review information in the profile is only as good as the system that performs data collection and peer review in the first place. This system must allow the retrieval of both “numerator” and “denominator” data so that percentages can be developed. Saying Dr. A. and Dr. B. both had two preventable serious complications is misleading without knowing their respective patient volumes.
In addition, the peer review system must be constructed appropriately. Such a system is based on an information flow that incorporates concurrent interaction with and feedback to the practitioner during the review process. The system summarizes the findings regarding the individual physician compared with a peer group. Such a system can be used to provide a summary report that can be easily reviewed by department directors, credentials committees, executive committees, or other bodies involved in the reappointment process and, if necessary, used to prompt further investigation of specific cases or issues.
Example of a Peer Review Profile Figure 4 demonstrates a peer review summary format that has been used successfully for this purpose at Carney Hospital in Boston for the past four years. This format allows the department director or other reviewer to quickly compare an individual practitioner with others in his or her department and with the medical staff as a whole in terms of the number of cases that show a significant exception to the established standard following secondary review. The profile must provide an adequate representation of volume of cases treated by the individual practitioner.
Making the Data Useful Physician profiles can be a very effective tool in maintaining a medical staff that uniformly meets established practice parameters, and they provide one avenue for continually improving practice through feedback. However, providing physician profile data to the department director, the Credentials Committee, and other reviewers certainly does not ensure the desired result. For example, it is very important to establish forms and report formats that are straightforward and easily interpreted. Reappointment applications must be present to the reviewer in sufficiently low numbers and on a timely basis to allow adequate time to assess each reappointment. “Batch” processing reappointment applications is unlikely to result in a thorough review process. Finally, experience shows that it is very important to orient - and, from time to time, reeducate - chiefs and committee members regarding the importance and proper use of all of the information that is contained in the reappointment materials - including the “physician profile.”
Figure 3 Flow Chart of the Peer Review Process
“Weighting” Data Elements As mentioned earlier, not all elements of the physician practice profile are of equal importance in the reappointment consideration. Each of the medical staff and clinical activities needs to be “weighted” in a manner agreed upon by the medical staff as a whole. A point system based upon aggregated scores of the physician profile items can be used to produce “scores” that, in turn, can be used to facilitate the reappointment review process.(4)
Avoiding Unnecessary “Issues” Often the review of an application for reappointment is “hung up” because the applicant has not met the expected standard for meeting attendance, has had an unacceptable number of medical records problems, or has fallen below expected hospital use rates. Each of these issues is important in the total profile of the physician’s relationship to the institution - but not for patient care-related reasons.
Figure 4 Sample Peer Review Summary Section of a Physician Performance Profile
In the instance of poor meeting attendance, the solution may rest in having more than one active staff category. For those who are clinically active at the institution but do not participate in medical staff meetings and other kinds of medical staff activities, a failure to reappoint would seem inappropriate as long as they adequately participate in quality assurance activities of the institution. On the other hand, physicians who do fulfill all of their staff obligations could be given a staff category that entitles them to such tings as lower dues, free parking, and other incentives that would reward them for the work they perform on behalf of the other less active members. The “scores” obtained through the weighting system can be successfully used to differentiate staff members into such categories (see Figure 5).
In the situation of the staff member who has frequent lapses in medical records completion, one is well advised to handle this as an administrative matter (with possible disciplinary consequences). The department chief can take a very useful role in discussing medical records issues with the practitioner as they occur and conveying on a personal level the importance of complete and timely medical records to good patient care. Such discussion also provides the opportunity to review the medical staff and departmental standards for record completion. If such standards do not exist, the department chief should work with the Executive Committee or department membership to establish them. Otherwise, medical record discussions with staff members can become very subjective and argumentative.
If the department chief’s intervention is unsuccessful, the physician may be asked to appear at a Medical Executive Committee to discuss corrective action. Only in the very unlikely event that this level of intervention should fail would medical records issues become an important reappointment consideration.
Figure 5
In the case of the physician who has relatively low volume at the institution, the categories of staff membership should include criteria for the volume of cases that the attending physician should care for at the institution. The “low volume” staff member is of particular difficulty in the reappointment process, because the organization has little basis on which to judge current competence. It becomes very important to seek adequate reference and peer review information from other institutions where the practitioner has staff membership. In those situations where it is not possible to satisfactorily confirm current competence, special measures such as might be used during the initial observation period of associate membership should be reinstituted or, if the volume has fallen below set criteria standards, then staff membership should be discontinued. Reappointment as an Opportunity for Communication The occasion of application for reappointment should be viewed as an opportunity by the department director to perform the equivalent of a performance evaluation with the staff member. In addition to the very important role of providing feedback to staff members regarding their “practice profile,” such a meeting provides a formal occasion to review with the staff their future practice, plans, and goals - and for the department director to set new goals and objectives and to discuss future departmental plans with staff members.
° ° °
Physician practice profiles codify medical staff participation expectations and standards for practice within the institution and are an essential tool in the reappointment process.
Department directors, credentials committees, and executive committees being asked to make reappointment decisions need objective bases for making judgments in a uniform manner. Internal and external comparative data, as appropriate, should be a part of the physician profile information that is developed. The profile must be presented in a format that is easily comprehended and interpreted so as to encourage careful consideration by the reappointment reviewers.
In addition, carefully prepared and easily readable profiles can be used as a centerpiece for discussion between the individual practitioner and the department chief at their biennial reappointment “performance review.” Careful attention to the preparation of physician profiles and adherence to a procedure that encourages communication of the materials and good discussion between department director and the individual practitioner will enhance the quality of medical practice within an institution.
Author John S. Coldiron, M.D., M.P.H. is the Vice President for Medical Management at Insight Health Solutions, Inc. He was the Vice President of Medical Affairs at Newport Hospital, Newport RI, from April 1995 to January 2003. In that position, he was primarily responsible for serving as liaison with the Hospital’s medical staff, organizing the Hospital’s total quality management program, developing and implementing a medical staff development plan, and contributing to the Hospital’s overall strategic planning process.
Prior to his appointment at Newport Hospital, he was Senior Vice President of Clinical Affairs, Massachusetts Hospital Association, Burlington, Massachusetts. From 1973 to 1981, he was Senior Vice President for Medical Affairs and Director and Vice President of Ambulatory and Community Services, Carney Hospital, Boston, Massachusetts. Also, at Carney Hospital, he served as Chief of Pediatrics and Director of Ambulatory Care Services from 1970 to 1973.
Dr. Coldiron received his MD from the University of Chicago, IL, completed a rotating internship at Robert Packer Hospital, Sayre, Pennsylvania, and a pediatric residency at Babies Hospital in New York City, NY. He received his Master’s degree in Public Health from Columbia University School of Public Health and Administrative Medicine, New York, NY in 1968. He is certified in Pediatrics and Medical Management and is a Fellow in the College of American Health Care Executives.
Active throughout his career on various health care advisory boards, Dr. Coldiron is currently a member of the Governing Committee of the Massachusetts Medical Malpractice Reinsurance Plan.
References
1. Koska, M.T. “JCAHO: Safety, Medical Staff Issues Hinder Compliance.” Hospitals. 66:48, April 5, 1992. See also, Hospital Accreditation Statistics 1987-1989. Chicago: Joint Commission on Accreditation of Healthcare Organizations, 31-33, 1992.
2. American Hospital Association. Practice Pattern Analysis: A Tool for Continuous Improvement of Patient Care Quality. Chicago: American Hospital Association, 1991.
3. “HCFA: New Committees to Address Physician Medicare Hassles.” Medical Staff Leader. p. 7, June 1992.
4. Haun, J.P. “A Process of Objective Review of Physician Performance.” Physician Executive. 18:51-55, May-June 1992.
This article was published in The Physician Leader's Guide Rockville, MD: Bader & Associates, Inc. 1992 pp 107-113 (First Edition) 1998 pp. 255-264 (Second Edition) |
