Transcript Document

Medical Staff Standards
Focus: Performance Review
Stephen M. Dorman, M.D.
www.redandgold.com
1
2009 Scoring and
Accreditation Decision Model
2
Standard
A statement that defines the performance
expectations and/or structures or
processes that must be in place in order
for a healthcare organization to provide
safe, high quality care, treatment, and
services.
An organization is either “compliant” or “
not compliant” with a standard.
3
Element of Performance
The specific performance expectation and/or
structure or process that must be in place
in order for a healthcare organization to
provide safe, high quality care, treatment,
and services.
The scoring of EP compliance determines
an organization’s overall compliance with
a standard.
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2009 Scoring/Accreditation Decision Model Summary
Elements of Performance (EP) will be
categorized by common scoring
characteristics
(e.g., Category A-yes/no, Category C multiple observations of non-compliance).
The use of Category B EPs (qualitative and
quantitative components) will be
discontinued.
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2009 Scoring/Accreditation Decision Model Summary
The frequency of bulleted EPs will be
reduced.
Elements of Performance and other
accreditation requirements will be tagged
based on their “criticality” – immediacy of
impact on quality of care and patient
safety as the result of noncompliance.
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2009 Scoring/Accreditation Decision Model Summary
DIRECT impact
INDIRECT impact
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2009 Scoring/Accreditation Decision Model Summary
All partially compliant and insufficiently compliant EPs must
be addressed via the Evidence of Standards Compliance
(ESC) submission process –
No “Supplemental” findings.
Potentially multiple submission deadlines based on the
“immediacy” of risk.
Direct Impact Requirements: ESC due within 45 days.
Indirect Impact Requirements: ESC due within 60 days.
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2009 Scoring/Accreditation Decision Model Summary
If partial compliance or insufficient
compliance is not resolved, a
progressively more adverse accreditation
decision may result:
Provisional, Conditional, Preliminary Denial
of Accreditation.
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2009 Scoring/Accreditation Decision Model Summary
Levels of Standards:
Immediate threat to life: no a single
standard, but condition
Situational Decision Rule: immediate
recommendation of Denial of Accreditation
or Conditional accreditation alone.
eg: unlicensed provider
Onsite validation
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2009 Scoring/Accreditation Decision Model Summary
DIRECT impact standard: Sedation
INDIRECT impact standard: Policies
New labels on standards:
(D): Documentation required
(2): Situational Decision Rule
(3): Direct Impact Requirements
(blank): Indirect Impact Requirements
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MS Chapter Outline
I. Medical Staff Bylaws
A. Bylaws (revised MS.01.01.01)
B. Unilateral Amendment (revised
MS.01.01.03)
II. Structure and Role of Medical Staff
Executive Committee (revised
MS.02.01.01)
12
MS Chapter Outline
III. Medical Staff Role in Oversight of Care,
Treatment, and Services
A. Oversight of Quality of Care (revised
MS.03.01.01)
B. Management and Coordination of Care
(revised MS.03.01.03)
13
MS Chapter Outline
IV. Medical Staff Role in Graduate Education
Programs (revised MS.04.01.01)
V. Medical Staff Role in Performance Improvement
A. Role in Performance Improvement Activities
(revised MS.05.01.01)
B. Participation in Performance Improvement
Activities (revised MS.05.01.03)
14
MS Chapter Outline
VI. Credentialing and Privileging
A. Determining Resource Availability (revised
MS.06.01.01)
B. Collecting Information (revised MS.06.01.03)
C. Decision Process (revised MS.06.01.05)
D. Reviewing Information (revised MS.06.01.07)
E. Communicating Decision (revised
MS.06.01.09)
F. Expedited Process (revised MS.06.01.11)
G. Temporary Privileges (revised MS.06.01.13)
15
MS Chapter Outline
VII. Appointment to Medical Staff
A. Recommending Appointment (revised
MS.07.01.01)
B. Peer Recommendations (revised
MS.07.01.03)
16
MS Chapter Outline
VIII. Evaluation of Practitioners
A. Monitoring Performance (revised
MS.08.01.01)
B. Use of Monitoring Information (revised
MS.08.01.03)
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MS Chapter Outline
IX. Acting on Reported Concerns About a
Practitioner (revised MS.09.01.01)
X. Fair Hearing and Appeal Process (revised
MS.10.01.01)
XI. Licensed Independent Practitioner
Health (revised MS.11.01.01)
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MS Chapter Outline
XII. Continuing Education for Practitioners
(revised MS.12.01.01)
XIII. Medical Staff Role in Telemedicine
A. Credentialing and Privileging of
Licensed Independent Practitioners
(revised MS.13.01.01)
B. Recommending Clinical Services to be
Provided (revised MS.13.01.03)
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MOVED STANDARDS
MS.1.10 -> LD.01.05.01
Standard LD.01.05.01
The organization has a medical staff that is
accountable to the governing body.
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LD.01.05.01
1: Single organized medical staff
2: Self-governing
3: Conforms to guiding principles
4: Governing body approves structure
5: Medical staff oversees quality care
provided by individuals with clinical
privileges
6: Accountable to governing body
21
MS.01.01.01
MS.1.20 (controversial)
All elements RETAINED (at least for now).
No new concepts pending rewriting this
standard
22
MS.03.01.01
Medical staff oversees quality of care,
treatments, or services provided by
practitioners privileged through the
medical staff process
1: LIPs designated to perform oversight
! 2: Practitioners practices within scope of
privileges
3: LIPs perform oversight
23
MS.03.01.01
4: Leadership in patient safety
5: Oversight of process of analyzing and
improving patient satisfaction
D 6: Minimal content of H&Ps defined
7: MS monitors quality of H&Ps
8: Privileged provider performs H&Ps
9: Others as allowed by laws may perform
H&Ps, under a specified physician
24
MS.03.01.01
D 10: Define when H&P must be validated
or countersigned
D 11: Defines scope of H&P when required
for non-inpatient services
25
MS.03.01.03
The management and coordination of
each patient’s care, treatment, or services
is the responsibility of a practitioner with
appropriate privileges
1: LIP with privileges manage and
coordinate patient’s care, treatment and
services
2: Hospital educates all LIPs on assessing
and managing pain (NEW)
26
MS.03.01.03
3: Patient’s general medical condition
managed by a physician.
4: Circumstances warranting consultation
5: Consultations obtained when warranted
6: Coordination of care among
practitioners
27
MS.05.01.01
The organized medical staff has a
leadership role in organization
performance improvement activities to
improve quality of care, treatment, and
services and [patient] safety.
Practitioner specific performance data.
28
MS.05.01.01
1: The organized medical staff provides
leadership for measuring, assessing, and
improving processes that primarily depend
on the activities of one or more licensed
independent practitioners, and other
practitioners credentialed and privileged
through the medical staff process.
29
MS.05.01.01
2: Medical assessment and treatment of
patients
3: Use of information about adverse
privileging decisions for any practitioner
privileged through the medical staff
process
4: Use of medications
30
MS.05.01.01
5: Use of blood and blood components
6: Operative and other procedure(s)
7: Appropriateness of clinical practice
patterns
8: Significant departures from established
patterns of clinical practice
9: The use of developed criteria for
autopsies.
31
MS.05.01.01
10: Sentinel event data
11: Patient safety data
32
MS.05.01.03
Practitioner specific data: citizenship
1: Education of patients and families
2: Coordination of care, treatment, and
services with other practitioners and
hospital personnel, as relevant to the care,
treatment, and services of an individual
patient.
33
MS.05.01.03
3: Accurate, timely, and legible completion
of patient’s medical records
4: Review of findings of the assessment
process that are relevant to an individual’s
performance. The organized medical staff
is responsible for determining the use of
this information in the ongoing
evaluations of a practitioner’s competence.
34
MS.05.01.03
5: Communication of findings, conclusions,
recommendations, and actions to improve
performance to appropriate staff members
and the governing body.
35
MS.06.01.01
Prior to granting a privilege, the resources
necessary to support the requested
privilege are determined to be currently
available, or available within a specified
time frame.
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MS.06.01.01
1: Process to determine sufficient: space,
equipment, staffing, and financial
resources are in place or time frame
defined to support requested privilege
2: The hospital consistently determines the
resources needed for each requested
privilege.
37
MS.06.01.03
The [organization] collects information
regarding each practitioner’s current
license status, training, experience,
competence, and ability to perform the
requested privilege.
38
MS.06.01.03
1: Clearly defined process
2: Process based on recommendations by
medical staff
3: Process approved by governing body
D 4: Outlined in bylaws
5: Verify identify: hospital ID card,
government issued ID (TO BE CHANGED)
39
MS.06.01.03
D 6: Primary Source verification of:
– The applicant’s current licensure at time of
initial granting, renewal, and revision of
privileges, and at the time of license
expiration.
– The applicant’s relevant training.
– The applicant’s current competence.
40
MS.06.01.05
The decision to grant or deny a
privilege(s), and/or to renew an existing
privilege(s), is an objective, evidencedbased process.
41
MS.06.01.05
! 1: All licensed independent practitioners
that provide care possess a current
license, certification, or registration, as
required by law and regulation.
(SITUATIONAL DECISION)
42
MS.06.01.05
D 2: Criteria based privileges include:
– Current licensure and/or certification, as appropriate,
verified with the primary source.
– The applicant’s specific relevant training, verified with
the primary source.
– Evidence of physical ability to perform the requested
privilege.
– Data from professional practice review by an
organization(s) that currently privileges the applicant
(if available).
– Peer and/or faculty recommendation.
– When renewing privileges, review of the practitioner’s
performance within the hospital.
43
MS.06.01.05
3: All of the criteria used are consistently
evaluated for all practitioners holding that
privilege
D 4: Process defined for granting,
renewing, revising privileges
5: Process is approved by medical staff
44
MS.06.01.05
D 6: Applicant submits health statement.
7: Hospital queries NPDB at initial
privileges, renewal of privileges, and when
new privileges requested.
45
MS.06.01.05
D 8: Peer Recommendation includes:
– Medical/Clinical knowledge.
– Technical and clinical skills.
– Clinical judgment.
– Interpersonal skills.
– Communication skills.
– Professionalism.
46
MS.06.01.05
9: Before recommending privileges, the organized
medical staff also evaluates the following:
– Challenges to any licensure or registration.
– Voluntary and involuntary relinquishment of any license or
registration.
– Voluntary and involuntary termination of medical staff
membership.
– Voluntary and involuntary limitation, reduction, or loss of clinical
privileges.
– Any evidence of an unusual pattern or an excessive number of
professional liability actions resulting in a final judgment against
the applicant.
– Documentation as to the applicant’s health status.
– Relevant practitioner-specific data as compared to aggregate
data, when available.
– Morbidity and mortality data, when available.
47
MS.06.01.05
10: The hospital has a process to
determine whether there is sufficient
clinical performance information to make a
decision to grant, limit, or deny the
requested privilege. (CMS)
C 11: Completed applications for privileges
are acted on within the time period
specified in the medical staff bylaws.
48
MS.06.01.05
12: Information regarding each
practitioner’s scope of privileges is
updated as changes in clinical privileges
for each practitioner are made.
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MS.06.01.07
The organized medical staff reviews and
analyzes all relevant information regarding
each requesting practitioner’s current
licensure status, training, experience,
current competence, and ability to perform
the requested privilege.
50
MS.06.01.07
1: The information review and analysis
process is clearly defined.
D 2: The hospital, based on
recommendations by the organized
medical staff and approval by the
governing body, develops criteria that will
be considered in the decision to grant,
limit, or deny a requested privilege.
51
MS.06.01.07
C 3: The hospital completes the credentialing
and privileging decision process in a timely
manner.
4: The hospital’s privilege granting /denial
criteria are consistently applied for each
requesting practitioner.
5: Decisions on membership and granting of
privileges include criteria that are directly related
to the quality of health care, treatment, and
services.
52
MS.06.01.07
6: If privileging criteria are used that are
unrelated to quality of care, treatment, and
services or professional competence,
evidence exists that the impact of resulting
decisions on the quality of care, treatment,
and services is evaluated.
53
MS.06.01.07
7: The governing body or delegated
governing body committee has final
authority for granting, renewing, or
denying privileges.
8: Privileges are granted for a period not to
exceed two years.
54
MS.06.01.09
The decision to grant, limit, or deny an
initially requested privilege or an existing
privilege petitioned for renewal is
communicated to the requesting
practitioner within the time frame specified
in the medical staff bylaws.
55
MS.06.01.09
1: Requesting practitioners are notified
regarding the granting decision.
2: In the case of privilege denial, the applicant is
informed of the reason for denial.
3: The decision to grant, deny, revise, or revoke
privilege(s) is disseminated and made available
to all appropriate internal and external persons
or entities, as defined by the hospital and
applicable law.
56
MS.06.01.09
D 4: The process to disseminate all
granting, modification, or restriction
decisions is approved by the organized
medical staff.
5: The hospital makes the practitioner
aware of available due process or, when
applicable, the option to implement the
Fair Hearing and Appeal Process for
Adverse Privileging Decisions.
57
MS.06.01.11
An expedited governing body approval
process may be used for initial
appointment and reappointment to the
medical staff and for granting privileges
when criteria for that process are met.
58
MS.06.01.11
D 1: The organized medical staff develops
criteria for an expedited process for granting
privileges. (two voting members)
2: The criteria provide that an applicant for
privileges is ineligible for the expedited process
if any of the following has occurred:
- The applicant submits an incomplete
application.
- The medical staff executive committee makes
a final recommendation that is adverse or has
limitations.
59
MS.06.01.11
Ineligible if:
3: There is a current challenge or a previously
successful challenge to licensure or registration.
4: The following situations are evaluated on a
case-by-case basis and usually result in
ineligibility for the expedited process: The
applicant has received an involuntary
termination of medical staff membership at
another hospital.
60
MS.06.01.11
Ineligible if:
5: The applicant has received involuntary
limitation, reduction, denial, or loss of
clinical privileges.
6: The hospital determines that there has
been either an unusual pattern of, or an
excessive number of, professional liability
actions resulting in a final judgment
against the applicant.
61
MS.06.01.11
7: The organized medical staff uses the
criteria developed for the expedited
process when recommending privileges.
62
MS.06.01.13
Under certain circumstances, temporary
clinical privileges may be granted for a
limited period of time.
1: Temporary privileges are granted to
meet an important patient care need for
the time period defined in the medical staff
bylaws.
63
MS.06.01.13
2: When temporary privileges are granted
to meet an important care need, the
organized medical staff verifies current
licensure and current competence.
64
MS.06.01.13
3: Temporary privileges for new applicants
may be granted while awaiting review and
approval by the organized medical staff
upon verification of the following:
– Current licensure.
– Relevant training or experience.
– Current competence.
65
MS.06.01.13
Verification (cont):
– Ability to perform the privileges requested.
– Other criteria required by the organized medical staff
bylaws.
– A query and evaluation of the National Practitioner
Data Bank (NPDB) information.
– A complete application.
– No current or previously successful challenge to
licensure or registration.
– No subjection to involuntary termination of medical
staff membership at another organization.
– No subjection to involuntary limitation, reduction,
denial, or loss of clinical privileges.
66
MS.06.01.13
4: All temporary privileges are granted by
the chief executive officer or authorized
designee.
5: All temporary privileges are granted on
the recommendation of the medical staff
president or authorized designee.
6: Temporary privileges for new applicants
are granted for no more than 120 days.
67
MS.07.01.01
The organized medical staff provides
oversight for the quality of care, treatment,
and services by recommending members
for appointment to the medical staff.
68
MS.07.01.01
D 1: The organized medical staff develops
criteria for medical staff membership.
2: The professional criteria are designed to
assure the medical staff and governing
body that patients will receive quality care,
treatment, and services.
69
MS.07.01.01
3: The organized medical staff uses the
criteria in appointing members to the
medical staff and appointment does not
exceed a period of two years.
4: Membership is recommended by the
medical staff and granted by the governing
body.
70
MS.07.01.03
Deliberations by the medical staff in
developing recommendations for
appointment to or termination from the
medical staff and for the initial granting,
revision, or revocation of clinical privileges
include information provided by peer(s) of
the applicant.
71
MS.07.01.03
1: Recommendations from peers are
obtained and evaluated for all new
applicants for privileges.
2: Upon renewal of privileges, when
insufficient practitioner-specific data are
available, the medical staff obtains and
evaluates peer recommendations.
72
MS.07.01.03
3: Peer recommendations include the
following information:
- Medical/Clinical knowledge.
- Technical and clinical skills.
- Clinical judgment.
- Interpersonal skills.
- Communication skills.
- Professionalism.
73
MS.07.01.03
4: Peer recommendations are obtained
from a practitioner in the same
professional discipline as the applicant
with personal knowledge of the applicant’s
ability to practice.
74
MS.08.01.01
The organized medical staff defines the
circumstances requiring monitoring and
evaluation of a practitioner’s professional
performance.
75
MS.08.01.01
1: A period of focused professional
practice evaluation is implemented for all
initially requested privileges.
D 2: The organized medical staff develops
criteria to be used for evaluating the
performance of practitioners when issues
affecting the provision of safe, high quality
patient care are identified.
76
MS.08.01.01
3: The performance monitoring process is clearly
defined and includes each of the following
elements:
- Criteria for conducting performance monitoring.
- Method for establishing a monitoring plan
specific to the requested privilege.
- Method for determining the duration of
performance monitoring.
- Circumstances under which monitoring by an
external source is required.
77
MS.08.01.01
4: Focused professional practice
evaluation is consistently implemented in
accordance with the criteria and
requirements defined by the organized
medical staff.
78
MS.08.01.01
5: The triggers that indicate the need for
performance monitoring are clearly
defined.
Note: Triggers can be single incidents or
evidence of a clinical practice trend.
79
MS.08.01.01
6: The decision to assign a period of
performance monitoring to further assess
current competence is based on the evaluation
of a practitioner’s current clinical competence,
practice behavior, and ability to perform the
requested privilege.
Note: Other existing privileges in good standing
should not be affected by this decision.
80
MS.08.01.01
D 7: Criteria are developed that determine
the type of monitoring to be conducted.
D 8: The measures employed to resolve
performance issues are clearly defined.
9: The measures employed to resolve
performance issues are consistently
implemented.
81
MS.08.01.03
Ongoing professional practice evaluation
information is factored into the decision to
maintain existing privilege(s), to revise
existing privilege(s), or to revoke an
existing privilege prior to or at the time of
renewal.
82
MS.08.01.03
D 1: The process for the ongoing
professional practice evaluation includes
the following: There is a clearly defined
process in place that facilitates the
evaluation of each practitioner’s
professional practice.
83
MS.08.01.03
2: The type of data to be collected is
determined by individual departments and
approved by the organized medical staff.
3: Information resulting from the ongoing
professional practice evaluation is used to
determine whether to continue, limit, or
revoke any existing privilege(s).
84
MS.09.01.01
The organized medical staff, pursuant to
the medical staff bylaws, evaluates and
acts upon reported concerns regarding a
privileged practitioner’s clinical practice
and/or competence.
85
MS.09.01.01
D 1: The hospital, based on
recommendations by the organized
medical staff and approval by the
governing body, has a clearly defined
process for collecting, investigating, and
addressing clinical practice concerns.
86
MS.09.01.01
2: Reported concerns regarding a
privileged practitioner’s professional
practice are uniformly investigated and
addressed, as defined by the hospital and
applicable law.
87
MS.11.01.01
The medical staff implements a process to
identify and manage matters of individual
health for licensed independent
practitioners which is separate from
actions taken for disciplinary purposes.
88
MS.11.01.01
1: Process design addresses the following
issues: Education of licensed independent
practitioners and other organization staff
about illness and impairment recognition
issues specific to licensed independent
practitioners (at-risk criteria).
89
MS.11.01.01
2: Self referral by a licensed independent
practitioner.
3: Referral by others and maintaining
informant confidentiality.
4: Referral of the licensed independent
practitioner to appropriate professional
internal or external resources for
evaluation, diagnosis, and treatment of the
condition or concern.
90
MS.11.01.01
5: Maintenance of confidentiality of the
licensed independent practitioner seeking
referral or referred for assistance, except
as limited by applicable law, ethical
obligation, or when the health and safety
of a patient is threatened.
91
MS.11.01.01
6: Evaluation of the credibility of a
complaint, allegation, or concern.
7: Monitoring the licensed independent
practitioner and the safety of patients until
the rehabilitation is complete and
periodically thereafter, if required.
92
MS.11.01.01
8: Reporting to the organized medical staff
leadership instances in which a licensed
independent practitioner is providing
unsafe treatment.
9: Initiating appropriate actions when a
licensed independent practitioner fails to
complete the required rehabilitation
program.
93
MS.11.01.01
10: The medical staff implements its
process to identify and manage matters of
individual health for licensed independent
practitioners.
94
MS.12.01.01
All licensed independent practitioners and
other practitioners privileged through the
medical staff process participate in
continuing education.
95
96
Physician Performance
Components of a compliant
process
97
CMS
CMS requires that physician
performance plans be defined in
writing. This is scored as part of
quality and not credentialing or
privileging.
98
Basics
Indicators must be established
that are appropriate to each
physician. Generally this is
specialty based.
Components to be included are
delineated in MS.05.01.01 and
MS.05.03.01
99
Indicator Development
Must originate at the department level
Must be approved by department
chairman
Must be approved by MEC
Must be approved by Governing body
100
Indicator Development
Many appropriate indicators are
already being measured within the
hospital:
– Core measures (internal medicine)
– SCIP measures (procedural specialties)
– Traditional review (LOS, denials)
– Medical records
101
Indicator Development
Some measures have been part of
generic screens:
– Returns to the operating room
– Returns to the emergency room
– Surgical site wound infections
– Critical events
102
Indicator Development
Some indicators are antiquated:
– C-Section rate
– Appropriateness of Appendectomies
103
Indicator Development
Commonly used indicators:
–ASA Indicator set:
Prolonged recovery for anesthesia
Failed regional anesthesia
Hypotension
Hypoxia
Difficult intubation
104
Indicator Development
Obstetrics:
– Fetal age at C-Section delivery
– 3rd and 4th degree lacerations for
delivery (morbidity)
– Appropriate management of labor (as
defined)
– Use of analgesia
105
Indicator Development
Radiology:
– “Over-reads” for diagnostic imaging
– Appropriateness and outcomes from
invasive radiology procedures
106
Indicator Development
Surgical Specialties:
– Appropriateness of selected procedures
(high risk, problem-prone)
– Outcomes:
Surgical site wound infection
Other post-operative morbidity
Mortality
107
Indicator Development
Psychiatry:
– Multi-drug therapy
– Restraint need
– Recidivism rate
– Appropriateness of evaluations
108
Data Use
The periodicity of data collection must
be defined, and the method of
collecting data defined:
– Retrospective review
– Concurrent review
109
Data Use
Once the indicators are established
and methodology developed for
collection of the data then the task of
analysis must occur.
Data analysis: Conversion of all raw
numbers to rate based performance.
Incumbent on having good
denominator data.
110
Data Use
Some data may be available on an
aggregate basis, but not at a
practitioner specific level:
– Core Measure data
– SCIP data
– Other PI data
111
Data Use
Once the rate based data is collected on
an individual basis, it must be compared to
“peer” or departmental performance.
The comparison must be analytical, and
indicate if sub-par performance is a simple
data variant, or truly statistically significant.
Tools will be required for this analysis.
112
Data Use
Once the organization has the ability
to define, collect, and analyze the
data, then the periodicity of review
must be determined.
Ongoing performance monitoring has
been stated by TJC to be at an
interval not greater than every 6
months.
113
Data Use
Who will be charged with the data
review?
Will it be the department chairmen?
Will be it a medical staff quality
function?
How will you demonstrate that this
ongoing review function is being
done?
114
Data Use
What happens now?
What will happen to variant
performance issues?
– FOCUSED REVIEW
The next review period should reveal
improvement. If not what will happen?
CLOSE LOOPS
115
Data Use
Now that data collection and analysis
is ongoing, it should be easy to
establish a comprehensive physician
based reappointment profile for
reappointment.
Performance data must then go to the
board for their consideration when
reappointments are being granted.
116
Data Use
What will go to board?
–Normal data?
–Variant data?
–Who will present this to board with
credentials file?
117
2009
For 2009, a focused review plan,
including the following will be required
for all initial appointments:
(provisional)
– How performance will be measured
– What indicators will be used
– Will the focused review be conducted as
direct observation, chart review?
118
2009
What determines “pass” or “fail”?
How will further evaluation be
conducted?
What will happen if the physician
performance in a sub-optimal?
How long will you wait to take action.
119
Indicators
Some events should not be “rated
based” such as sentinel or critical
events. Even one is too many, such
as “intra-operative anesthesia death.”
These types of cases should be
defined as requiring immediate
“focused review.”
120
Plan
Define indicators
Obtain department and leadership
approval
Formulate a “data inventory” and specify
methodology for data collection
Establish reporting chain of command
Write the plan
Define focused review
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Plan
Define ongoing review
Establish a methodology to write
focused review plans for all new
appointments to the medical staff as
of 2008.
Establish methodology for statistical
analysis.
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Challenges
Most data collection is manual. Extra staff
will probably be required.
Data collection and analysis is not a job
that is normally undertaken by the medical
staff office, but usually originates from the
performance measurement department
(quality).
Expertise must be acquired for analysis.
123
Questions?
124