1 Medical Staff Standards Focus: Performance Review Stephen M. Dorman, M.D. .

11

Medical Staff StandardsMedical Staff StandardsFocus: Performance ReviewFocus: Performance Review

Stephen M. Dorman, M.D.Stephen M. Dorman, M.D.

www.redandgold.comwww.redandgold.com

22

2009 Scoring andAccreditation Decision Model

33

StandardStandard

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.

44

Element of PerformanceElement 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.

55

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.

66


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.

77


DIRECT impactDIRECT impact

INDIRECT impactINDIRECT impact

88


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.

99


If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result:

Provisional, Conditional, Preliminary Denial of Accreditation.

1010


Levels of Standards:Levels of Standards:

Immediate threat to life: no a single Immediate threat to life: no a single standard, but conditionstandard, but condition

Situational Decision Rule: immediate Situational Decision Rule: immediate recommendation of Denial of Accreditation recommendation of Denial of Accreditation or Conditional accreditation alone.or Conditional accreditation alone.

eg: unlicensed providereg: unlicensed provider

Onsite validationOnsite validation

1111


DIRECT impact standard: SedationDIRECT impact standard: Sedation

INDIRECT impact standard: PoliciesINDIRECT impact standard: Policies

New labels on standards:New labels on standards:

(D): Documentation required

(2): Situational Decision Rule

(3): Direct Impact Requirements

(blank): Indirect Impact Requirements

1212

MS Chapter OutlineMS 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)

1313


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)

1414


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)

1515


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)

1616


VII. Appointment to Medical Staff

A. Recommending Appointment (revised MS.07.01.01)

B. Peer Recommendations (revised MS.07.01.03)

1717


VIII. Evaluation of Practitioners

A. Monitoring Performance (revised MS.08.01.01)

B. Use of Monitoring Information (revised MS.08.01.03)

1818


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)

1919


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)

2020

MOVED STANDARDSMOVED STANDARDS

MS.1.10 -> LD.01.05.01MS.1.10 -> LD.01.05.01

Standard LD.01.05.01

The organization has a medical staff that The organization has a medical staff that is accountable to the governing body.is accountable to the governing body.

2121

LD.01.05.01LD.01.05.01

1: Single organized medical staff1: Single organized medical staff

2: Self-governing2: Self-governing

3: Conforms to guiding principles3: Conforms to guiding principles

4: Governing body approves structure4: Governing body approves structure

5: Medical staff oversees quality care 5: Medical staff oversees quality care provided by individuals with clinical provided by individuals with clinical privilegesprivileges

6: Accountable to governing body6: Accountable to governing body

2222

MS.01.01.01MS.01.01.01

MS.1.20 (controversial)MS.1.20 (controversial)

All elements RETAINED (at least for now).All elements RETAINED (at least for now).

No new concepts pending rewriting this No new concepts pending rewriting this standardstandard

2323

MS.03.01.01MS.03.01.01

Medical staff oversees quality of care, Medical staff oversees quality of care, treatments, or services provided by treatments, or services provided by practitioners privileged through the practitioners privileged through the medical staff processmedical staff process

1: LIPs designated to perform oversight1: LIPs designated to perform oversight

! 2: Practitioners practices within scope of ! 2: Practitioners practices within scope of privilegesprivileges

3: LIPs perform oversight3: LIPs perform oversight

2424

MS.03.01.01MS.03.01.01

4: Leadership in patient safety4: Leadership in patient safety

5: Oversight of process of analyzing and 5: Oversight of process of analyzing and improving patient satisfactionimproving patient satisfaction

D 6: Minimal content of H&Ps definedD 6: Minimal content of H&Ps defined

7: MS monitors quality of H&Ps7: MS monitors quality of H&Ps

8: Privileged provider performs H&Ps8: Privileged provider performs H&Ps

9: Others as allowed by laws may perform 9: Others as allowed by laws may perform H&Ps, under a specified physicianH&Ps, under a specified physician

2525

MS.03.01.01MS.03.01.01

D 10: Define when H&P must be validated D 10: Define when H&P must be validated or countersignedor countersigned

D 11: Defines scope of H&P when D 11: Defines scope of H&P when required for non-inpatient servicesrequired for non-inpatient services

2626

MS.03.01.03MS.03.01.03

The management and coordination of The management and coordination of each patient’s care, treatment, or services each patient’s care, treatment, or services is the responsibility of a practitioner with is the responsibility of a practitioner with appropriate privilegesappropriate privileges1: LIP with privileges manage and 1: LIP with privileges manage and coordinate patient’s care, treatment and coordinate patient’s care, treatment and servicesservices2: Hospital educates all LIPs on assessing 2: Hospital educates all LIPs on assessing and managing pain (NEW)and managing pain (NEW)

2727

MS.03.01.03MS.03.01.03

3: Patient’s general medical condition 3: Patient’s general medical condition managed by a physician.managed by a physician.

4: Circumstances warranting consultation4: Circumstances warranting consultation

5: Consultations obtained when warranted5: Consultations obtained when warranted

6: Coordination of care among 6: Coordination of care among practitionerspractitioners

2828

MS.05.01.01MS.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.

2929

MS.05.01.01MS.05.01.01

1: 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.

3030

MS.05.01.01MS.05.01.01

2: 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

3131

MS.05.01.01MS.05.01.01

5: 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.

3232

MS.05.01.01MS.05.01.01

10: 10: Sentinel event data

11: Patient safety data

3333

MS.05.01.03MS.05.01.03

Practitioner specific data: citizenshipPractitioner specific data: citizenship

1: 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.

3434

MS.05.01.03MS.05.01.03

3: 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.

3535

MS.05.01.03MS.05.01.03

5: 5: Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

3636

MS.06.01.01MS.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.

3737

MS.06.01.01MS.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.

3838

MS.06.01.03MS.06.01.03

The [organization] collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

3939

MS.06.01.03MS.06.01.03

1: Clearly defined process1: Clearly defined process

2: Process based on recommendations by 2: Process based on recommendations by medical staffmedical staff

3: Process approved by governing body3: Process approved by governing body

D 4: Outlined in bylawsD 4: Outlined in bylaws

5: Verify identify: hospital ID card, 5: Verify identify: hospital ID card, government issued ID (TO BE CHANGED) government issued ID (TO BE CHANGED)

4040

MS.06.01.03MS.06.01.03

D 6: Primary Source verification of: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.

4141

MS.06.01.05MS.06.01.05

The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.

4242

MS.06.01.05MS.06.01.05

! 1: ! 1: All licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation. (SITUATIONAL DECISION)

4343

MS.06.01.05MS.06.01.05

D 2: Criteria based privileges include: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.

4444

MS.06.01.05MS.06.01.05

3: 3: All of the criteria used are consistently evaluated for all practitioners holding that privilege

D 4: Process defined for granting, D 4: Process defined for granting, renewing, revising privilegesrenewing, revising privileges

5: Process is approved by medical staff5: Process is approved by medical staff

4545

MS.06.01.05MS.06.01.05

D 6: Applicant submits health statement.D 6: Applicant submits health statement.

7: Hospital queries NPDB at initial 7: Hospital queries NPDB at initial privileges, renewal of privileges, and when privileges, renewal of privileges, and when new privileges requested.new privileges requested.

4646

MS.06.01.05MS.06.01.05

D 8: Peer Recommendation includes:D 8: Peer Recommendation includes:– Medical/Clinical knowledge.– Technical and clinical skills.– Clinical judgment.– Interpersonal skills.– Communication skills.– Professionalism.

4747

MS.06.01.05MS.06.01.05

9: 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.

4848

MS.06.01.05MS.06.01.05

10: 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.

4949

MS.06.01.05MS.06.01.05

12: 12: Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made.

5050

MS.06.01.07MS.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.

5151

MS.06.01.07MS.06.01.07

1: 1: The information review and analysis process is clearly defined.

D 2: 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.

5252

MS.06.01.07MS.06.01.07

C 3: C 3: The hospital completes the credentialing and privileging decision process in a timely manner.4: 4: The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner.5: 5: Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.

5353

MS.06.01.07MS.06.01.07

6: 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.

5454

MS.06.01.07MS.06.01.07

7: 7: The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges.

8: 8: Privileges are granted for a period not to exceed two years.

5555

MS.06.01.09MS.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.

5656

MS.06.01.09MS.06.01.09

1: 1: Requesting practitioners are notified regarding the granting decision.

2: 2: In the case of privilege denial, the applicant is informed of the reason for denial.

3: 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.

5757

MS.06.01.09MS.06.01.09

D 4: D 4: The process to disseminate all granting, modification, or restriction decisions is approved by the organized medical staff.5: 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.

5858

MS.06.01.11MS.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.

5959

MS.06.01.11MS.06.01.11

D 1: 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.

6060

MS.06.01.11MS.06.01.11

Ineligible if:Ineligible if:

3: 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.

6161

MS.06.01.11MS.06.01.11

Ineligible if:Ineligible if:5: 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.

6262

MS.06.01.11MS.06.01.11

7: 7: The organized medical staff uses the criteria developed for the expedited process when recommending privileges.

6363

MS.06.01.13MS.06.01.13

Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.

1: 1: Temporary privileges are granted to meet an important patient care need for the time period defined in the medical staff bylaws.

6464

MS.06.01.13MS.06.01.13

2: 2: When temporary privileges are granted to meet an important care need, the organized medical staff verifies current licensure and current competence.

6565

MS.06.01.13MS.06.01.13

3: 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.

6666

MS.06.01.13MS.06.01.13

Verification (cont):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.

6767

MS.06.01.13MS.06.01.13

4: 4: All temporary privileges are granted by the chief executive officer or authorized designee.

5: 5: All temporary privileges are granted on the recommendation of the medical staff president or authorized designee.

6: 6: Temporary privileges for new applicants are granted for no more than 120 days.

6868

MS.07.01.01MS.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.

6969

MS.07.01.01MS.07.01.01

D 1: D 1: The organized medical staff develops criteria for medical staff membership.

2: 2: The professional criteria are designed to assure the medical staff and governing body that patients will receive quality care, treatment, and services.

7070

MS.07.01.01MS.07.01.01

3: 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.

7171

MS.07.01.03MS.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.

7272

MS.07.01.03MS.07.01.03

1: 1: Recommendations from peers are obtained and evaluated for all new applicants for privileges.

2: 2: Upon renewal of privileges, when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations.

7373

MS.07.01.03MS.07.01.03

3: 3: Peer recommendations include the following information:

- Medical/Clinical knowledge. - Technical and clinical skills. - Clinical judgment. - Interpersonal skills. - Communication skills. - Professionalism.

7474

MS.07.01.03MS.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.

7575

MS.08.01.01MS.08.01.01

The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

7676

MS.08.01.01MS.08.01.01

1: 1: A period of focused professional practice evaluation is implemented for all initially requested privileges.

D 2: 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.

7777

MS.08.01.01MS.08.01.01

3: 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.

7878

MS.08.01.01MS.08.01.01

4: 4: Focused professional practice evaluation is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

7979

MS.08.01.01MS.08.01.01

5: 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.

8080

MS.08.01.01MS.08.01.01

6: 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.

8181

MS.08.01.01MS.08.01.01

D 7: D 7: Criteria are developed that determine the type of monitoring to be conducted.

D 8: D 8: The measures employed to resolve performance issues are clearly defined.

9: 9: The measures employed to resolve performance issues are consistently implemented.

8282

MS.08.01.03MS.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.

8383

MS.08.01.03MS.08.01.03

D 1: 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.

8484

MS.08.01.03MS.08.01.03

2: 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).

8585

MS.09.01.01MS.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.

8686

MS.09.01.01MS.09.01.01

D 1: 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.

8787

MS.09.01.01MS.09.01.01

2: 2: Reported concerns regarding a privileged practitioner’s professional practice are uniformly investigated and addressed, as defined by the hospital and applicable law.

8888

MS.11.01.01MS.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.

8989

MS.11.01.01MS.11.01.01

1: 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).

9090

MS.11.01.01MS.11.01.01

2: 2: Self referral by a licensed independent practitioner.3: 3: Referral by others and maintaining informant confidentiality.4: 4: Referral of the licensed independent practitioner to appropriate professional internal or external resources for evaluation, diagnosis, and treatment of the condition or concern.

9191

MS.11.01.01MS.11.01.01

5: 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.

9292

MS.11.01.01MS.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.

9393

MS.11.01.01MS.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.

9494

MS.11.01.01MS.11.01.01

10: 10: The medical staff implements its process to identify and manage matters of individual health for licensed independent practitioners.

9595

MS.12.01.01MS.12.01.01

All licensed independent practitioners and other practitioners privileged through the medical staff process participate in continuing education.

9696

9797

Physician Performance Physician Performance

Components of a compliant Components of a compliant processprocess

9898

CMSCMS

CMS requires that physician CMS requires that physician performance plans be defined in performance plans be defined in writing. This is scored as part of writing. This is scored as part of quality and not credentialing or quality and not credentialing or privileging.privileging.

9999

BasicsBasics

Indicators must be established Indicators must be established that are appropriate to each that are appropriate to each physician. Generally this is physician. Generally this is specialty based.specialty based.

Components to be included are Components to be included are delineated in MS.05.01.01 and delineated in MS.05.01.01 and MS.05.03.01MS.05.03.01

100100

Indicator DevelopmentIndicator Development

Must originate at the department levelMust originate at the department level

Must be approved by department Must be approved by department chairmanchairman

Must be approved by MECMust be approved by MEC

Must be approved by Governing bodyMust be approved by Governing body

101101


Many appropriate indicators are Many appropriate indicators are already being measured within the already being measured within the hospital:hospital:– Core measures (internal medicine)Core measures (internal medicine)

– SCIP measures (procedural specialties)SCIP measures (procedural specialties)

– Traditional review (LOS, denials)Traditional review (LOS, denials)

– Medical recordsMedical records

102102


Some measures have been part of Some measures have been part of generic screens:generic screens:– Returns to the operating roomReturns to the operating room

– Returns to the emergency roomReturns to the emergency room

– Surgical site wound infectionsSurgical site wound infections

– Critical eventsCritical events

103103


Some indicators are antiquated:Some indicators are antiquated:

– C-Section rateC-Section rate

– Appropriateness of AppendectomiesAppropriateness of Appendectomies

104104


Commonly used indicators:Commonly used indicators:–ASA Indicator set:ASA Indicator set:

Prolonged recovery for anesthesiaProlonged recovery for anesthesia

Failed regional anesthesiaFailed regional anesthesia

HypotensionHypotension

HypoxiaHypoxia

Difficult intubationDifficult intubation

105105


Obstetrics:Obstetrics:– Fetal age at C-Section deliveryFetal age at C-Section delivery

– 33rdrd and 4 and 4thth degree lacerations for degree lacerations for delivery (morbidity)delivery (morbidity)

– Appropriate management of labor (as Appropriate management of labor (as defined)defined)

– Use of analgesiaUse of analgesia

106106


Radiology:Radiology:– ““Over-reads” for diagnostic imagingOver-reads” for diagnostic imaging

– Appropriateness and outcomes from Appropriateness and outcomes from invasive radiology proceduresinvasive radiology procedures

107107


Surgical Specialties:Surgical Specialties:– Appropriateness of selected procedures Appropriateness of selected procedures

(high risk, problem-prone)(high risk, problem-prone)

– Outcomes:Outcomes:Surgical site wound infectionSurgical site wound infection

Other post-operative morbidityOther post-operative morbidity

MortalityMortality

108108


Psychiatry:Psychiatry:– Multi-drug therapyMulti-drug therapy

– Restraint needRestraint need

– Recidivism rateRecidivism rate

– Appropriateness of evaluationsAppropriateness of evaluations

109109

Data UseData Use

The periodicity of data collection must The periodicity of data collection must be defined, and the method of be defined, and the method of collecting data defined:collecting data defined:– Retrospective reviewRetrospective review

– Concurrent reviewConcurrent review

110110

Data UseData Use

Once the indicators are established Once the indicators are established and methodology developed for and methodology developed for collection of the data then the task of collection of the data then the task of analysis must occur.analysis must occur.

Data analysis: Conversion of all raw Data analysis: Conversion of all raw numbers to rate based performance.numbers to rate based performance.

Incumbent on having good Incumbent on having good denominator data.denominator data.

111111

Data UseData Use

Some data may be available on an Some data may be available on an aggregate basis, but not at a aggregate basis, but not at a practitioner specific level:practitioner specific level:– Core Measure dataCore Measure data

– SCIP dataSCIP data

– Other PI dataOther PI data

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Data UseData Use

Once the rate based data is collected on Once the rate based data is collected on an individual basis, it must be compared to an individual basis, it must be compared to “peer” or departmental performance.“peer” or departmental performance.

The comparison must be analytical, and The comparison must be analytical, and indicate if sub-par performance is a simple indicate if sub-par performance is a simple data variant, or truly statistically significant.data variant, or truly statistically significant.

Tools will be required for this analysis.Tools will be required for this analysis.

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Data UseData Use

Once the organization has the ability Once the organization has the ability to define, collect, and analyze the to define, collect, and analyze the data, then the periodicity of review data, then the periodicity of review must be determined.must be determined.

Ongoing performance monitoring has Ongoing performance monitoring has been stated by TJC to be at an been stated by TJC to be at an interval not greater than every 6 interval not greater than every 6 months.months.

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Data UseData Use

Who will be charged with the data Who will be charged with the data review?review?

Will it be the department chairmen?Will it be the department chairmen?

Will be it a medical staff quality Will be it a medical staff quality function?function?

How will you demonstrate that this How will you demonstrate that this ongoing review function is being done?ongoing review function is being done?

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Data UseData Use

What happens now?What happens now?

What will happen to variant What will happen to variant performance issues?performance issues?– FOCUSED REVIEWFOCUSED REVIEW

The next review period should reveal The next review period should reveal improvement. If not what will happen?improvement. If not what will happen?

CLOSE LOOPSCLOSE LOOPS

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Data UseData Use

Now that data collection and analysis Now that data collection and analysis is ongoing, it should be easy to is ongoing, it should be easy to establish a comprehensive physician establish a comprehensive physician based reappointment profile for based reappointment profile for reappointment.reappointment.

Performance data must then go to the Performance data must then go to the board for their consideration when board for their consideration when reappointments are being granted.reappointments are being granted.

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Data UseData Use

What will go to board?What will go to board?–Normal data?Normal data?

–Variant data?Variant data?

–Who will present this to board with Who will present this to board with credentials file?credentials file?

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20092009

For 2009, a focused review plan, For 2009, a focused review plan, including the following will be required including the following will be required for all initial appointments: for all initial appointments: (provisional)(provisional)– How performance will be measuredHow performance will be measured

– What indicators will be usedWhat indicators will be used

– Will the focused review be conducted as Will the focused review be conducted as direct observation, chart review?direct observation, chart review?

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20092009

What determines “pass” or “fail”?What determines “pass” or “fail”?

How will further evaluation be How will further evaluation be conducted?conducted?

What will happen if the physician What will happen if the physician performance in a sub-optimal?performance in a sub-optimal?

How long will you wait to take action.How long will you wait to take action.

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IndicatorsIndicators

Some events should not be “rated Some events should not be “rated based” such as sentinel or critical based” such as sentinel or critical events. Even one is too many, such events. Even one is too many, such as “intra-operative anesthesia death.”as “intra-operative anesthesia death.”

These types of cases should be These types of cases should be defined as requiring immediate defined as requiring immediate “focused review.”“focused review.”

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PlanPlan

Define indicatorsDefine indicators

Obtain department and leadership Obtain department and leadership approvalapproval

Formulate a “data inventory” and specify Formulate a “data inventory” and specify methodology for data collectionmethodology for data collection

Establish reporting chain of commandEstablish reporting chain of command

Write the planWrite the plan

Define focused reviewDefine focused review

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PlanPlan

Define ongoing reviewDefine ongoing review

Establish a methodology to write Establish a methodology to write focused review plans for all new focused review plans for all new appointments to the medical staff as appointments to the medical staff as of 2008. of 2008.

Establish methodology for statistical Establish methodology for statistical analysis.analysis.

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ChallengesChallenges

Most data collection is manual. Extra staff Most data collection is manual. Extra staff will probably be required.will probably be required.

Data collection and analysis is not a job Data collection and analysis is not a job that is normally undertaken by the medical that is normally undertaken by the medical staff office, but usually originates from the staff office, but usually originates from the performance measurement department performance measurement department (quality).(quality).

Expertise must be acquired for analysis.Expertise must be acquired for analysis.

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Questions?Questions?

Date post:	24-Dec-2015
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1 Medical Staff Standards Focus: Performance Review Stephen M. Dorman, M.D. .

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