medical staff standards for a clinical leader part 2 v2

Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

Application of the Medical Staff Standards in an Academic Division of General Internal Medicine

Medical Staff Standards What a clinical chief needs to know for employed physicians.

Part 2

Applying the Joint Commission Medical Staff Guidelines


Introduction

The following contains details on the application of the medical staff standards in an academic division of internal medicine. Contents include:1. Framework for Quality 2. Organizational hierarchy and assumptions3. Clinical data reporting hierarchy4. Clinical services under Internal Medicine and Adult Primary Care5. Employment models and staff categories6. Sources of data for practitioner evaluation7. Methods of practitioner reporting8. Professional Practitioner Evaluation

1. Framework – Cycle of evaluations2. Focused Professional Practitioner Evaluation (FPPE)3. Ongoing Professional Practitioner Evaluation (OPPE)4. Continuous Professional Practitioner Evaluation (CPPE)

9. Example of proposed OPPE for Internal Medicine and Adult Primary Care


Framework for Quality

In order to begin the discussion on objective performance based evaluation of physicians, it is important to outline the domains of quality that we operate under. Quality can be separated into five distinct areas:

– Safety - Avoidance of error or avoidance of anticipated negative effect from an intervention

– Engagement - Customer satisfaction– Clinical Quality - Application of evidence based medical interventions for specific clinical

conditions at both the patient and population level– Communication - Transfer of relevant clinical information to the next provider of care– Value - Improving the application of care for a patient or a population of patients in a

resource constrained environment (Value=Quality/Cost)


Administrative activities of the Division

Medical Staff Standards – Internal MedicineInternal Medicine within the Medical Center Hierarchy

Hospital

Clinical activities of the Division

Medical Staff

Nurse practitionersMD/DO

Internal Medicineand Adult Primary Care

Medical Students

Residents

Chief, Division of Internal Medicine – accountable individual

Division of Internal Medicine and Adult Primary Care

Organizational assumptions1. Transparency2. Practitioner clinical autonomy3. Alignment of strategy, tactics and

operations4. Balanced compensation program5. Appropriate staffing model and support6. Information technology infrastructure


Hierarchy for clinical reporting

Department of Medicine(PO)

Internal Medicine and Adult Primary Care

GMA/PDC

Quality

Clinical metrics

EMR: DM

and scripts

Registry data: HEDIS measures

Chart review

Interview

with

practitioner

Patient satisfact

ion

MHQP

Press-Ganey

Practice metrics

EMR: Chart

completion

IDX: wRVU

and volume

stats

Inpatient services

Core Measures

Medical Records

Press-Ganey Inpatient

Medical StaffPCA Committee

PPE Case reports


• Medicine– Internal Medicine

• Primary Care– Chronic care management– Urgent care– Health Screening and maintenance

• Inpatient Medicine– Acute care medicine– Rehab and sub-acute medicine

• Consultative Medicine• Geriatrics• Home based care• Transitional Care (Pediatric to adult transitions of care)

– Family Medicine• Primary Care (same as listed above)

• Cross specialty clinical services– Acupuncture

Medical Staff Standards – Internal MedicineClinical services in Internal Medicine and Adult Primary Care


• Employed by Tufts Medical Center PO– Clinical duties at Tufts Medical Center Campus (Active Staff)

• In GMA or PDC• In other ambulatory practices • Inpatient (as inpatient attending or consult attending)

– Clinical duties located at offsite ambulatory practice location (PO Associate Staff)

– Clinical duties located at another facility that has performance data (PO Associate Staff

• Not employed by Tufts Medical Center PO (Associate Staff)– Clinical duties located at offsite ambulatory practice– Clinical duties located at another facility that has performance data

Medical Staff Standards – Internal MedicineEmployment arrangements and clinical status


• Manual evaluative processes– Encounter visit note review (all venues)– Direct observation– One on one retrospective case reviews (interview with practitioner)

• Information Technology– Electronic Medical Records– Billing system– Clinical information systems– Dr. Quality

• External observations, measurements and surveys– Registry / HEDIS measures– Patient satisfaction surveys

• Press-Ganey• MHQP

Medical Staff Standards – Internal MedicineSources of individual practitioner clinical and administrative data


• Summary reports for multiple clinical and administrative measures for a specific responsible practitioner (snapshot)– Example: practitioner report in panel size, wRVUs, diabetes measures, medical student

teaching and conference attendance• Summary reports for one to many clinical and administrative measures by

responsible practitioner compared to practice average, benchmark/goal and peers (snapshot)– Example: Practice report with practitioners listed in rows and measures such as panel

size, average wRVU per patient, number of diabetics, average DM measure• Cumulative progress reports compared to peers for administrative and clinical

measures by responsible practitioner and compared to peers, benchmark and practice average (time average report for a defined period)

• Documentation log or review sheet. Report with either detail or summary information compiled as part of a chart review performed by chair/chief or other designated individual for the department/division

• Detail patient level reports from which summary statistics will be generated

Medical Staff Standards – Internal MedicineMethods of practitioner reporting


The Professional Practitioner Review Process


Cycle of practitioner evaluations

Ongoing Professional Practitioner Evaluation (OPPE) – every 2 years

Continuous Professional Practitioner Evaluation

(CPPE)monthly

Continuous Professional Practitioner Evaluation is not described in the Joint Commission standard


• Applies to newly hired faculty in the division• Occurs at 120 days after the first clinically active day• Performed by Chief of the division• Data reviewed

– Encounter documentation– One on one case retrospective reviews– Panel size– Visit volume– Input from other members of the clinical teams including, RNs, NPs, and

administrative staff– Patient feedback, if available

• Outcomes– Recommend continuation of privileges as originally granted– Extend period of focus review– Modify privileges based on FPPE– Suspend, revoke or terminate based on performance

Medical Staff Standards – Internal MedicineFocus Professional Practitioner Review (FPPE) – new faculty (full or part time)


• Applies to Chief Medical Residents (CMR) who have limited clinical duties mostly related to inpatient and consultative medicine

• The CMRs do not perform clinical duties within the first 120 days after starting in July. Their evaluation will occur within 30 days after finishing first inpatient or consult rotation

• Performed by Chief of the division• Data reviewed

– Encounter documentation– One on one case retrospective reviews– Joint Commission core measures, if available and applicable – Visit volume– Input from other members of the clinical teams including, RNs, NPs, and administrative staff– Patient feedback, if available

• Outcomes– The CMRs are employed by the Department of Medicine – any change in status requires consultation

with the Chair of Medicine and Residency Program Director. Any decisions regarding the clinical duties of the CMRs in the clinic and inpatient services is ultimately made by the Chief of Internal Medicine and Adult Primary Care. Based on the review, the chief can:

• Recommend to continue as originally privileged • Extend period of focused review• Modify privileges• Revoke privileges

Medical Staff Standards – Internal MedicineFocus Professional Practitioner Review (FPPE) – chief medical residents


• Applies to all practitioners credentialed and privileged in General Internal Medicine. • Period – every two years• Performed by Chief of the division• Data reviewed*

– Encounter documentation– Medication usage reports– Patterns of clinical management (process and outcome) based on quality initiatives for the division– One on one case retrospective reviews– Joint Commission core measures, if available and applicable – Panel size– Visit volume– Input from other members of the clinical teams including, RNs, NPs, and administrative staff– Patient feedback and survey results, if available

• Outcomes– Recommend to continue as originally privileged – Modify privileges– Revoke privileges

Medical Staff Standards – Internal MedicineOngoing Professional Practitioner Review (OPPE)

* - metrics revised annually based on clinical and business requirements of the practice


• Applies to all practitioners credentialed and privileged in General Internal Medicine. • Period – every month• Performed by Chief of the division• Data reviewed*

– Visit and practice statistics (will not affect medical staff status – collected and reported for practice and comparison purposes)

• Visit volume• wRVU• Panel size• Percent of patients with a future appointment• Percent of patients seen by PCP prior month

– Documentation• Office note completion

– Medication usage • % Controlled substances written by practitioner as PCP

– Medical Care (HEDIS measures) compared to peers• Diabetes care measures (process and outcome) • Hypertension

• Outcomes– Continue privileges as originally granted– Institute corrective action plan with a timeline– Modify privileges

Medical Staff Standards – Internal MedicineContinuous Professional Practitioner Review (CPPE)

* - metrics revised annually based on clinical and business requirements of the practice


2010 Metrics

Internal Medicine and Adult Primary Care


• Demographic information– Clinical practice

• Ambulatory primary care• Ambulatory urgent care• Inpatient medicine• Consultative medicine

– Clinical time commitment• % clinical FTE

– Baseline• Practice characteristics • Panel size• Visit volume• wRVUs per case and cumulative

• Metrics– Non-clinical

• Office note completion• Meeting attendance*• Divisional activities*

– Clinical• Diabetes measure*• % of narcotic script refilled by PCP• Problem list completion

– Education• Medical student notes completed*

* - denote measure used in annual incentive compensation calculation

Medical Staff Standards – Internal Medicine2010 metrics


Practical approach to completing a professional practitioner review

Process review and examples of reports and paperwork


1. Outline/list clinical work clinician provides– Clinical areas– % effort

2. Quantitative report results– Practice demographics– Quality

• Diabetes• Narcotic consistency in prescribing

– Engagement– Clinical teaching activities– Practice measures

• Incomplete medical records• Problem list completion

3. Qualitative – Narrative description summary of the practitioner’s clinical work– List awards, honors and other recognition obtained since the last review– If the practitioner is not meeting goals then the following should be outlined

• Problem area(s)• Possible causative factors• What steps have been taken to date• Steps that will be taken• Timeframe for re-evaluation

* - denote measure used in annual incentive compensation calculation

Medical Staff Standards – Internal MedicineProcess – Professional Practice Evaluation


Sample OPPE report with data

Outline and list clinical duties provided by the practitioner

Provide baseline volume statistics

List quality measures being tracked by the division with corresponding data and goals

List other areas of interest to the division with corresponding data

Finish with a narrative description of the practitioner’s clinical work and summary evaluation. If practitioner is not achieving goals – outline corrective action plan. List awards and honors.

medical staff standards for a clinical leader part 2 v2

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