How to obtain the data for medical staff standards

You'll need data for every practitioner

Data for every practitioner, analyzed frequently, with the right people in the loop — you'll need to develop systems to ensure that all of these things happen on an ongoing basis, in order to comply with new medical staff standards from The Joint Commission.

"I had one organization say to me, 'Our departments all meet monthly and they look at all the data that is available monthly. Is that OK?' My question was, 'I like the frequency and that you are looking at all the data, but do you have data for everyone?'" says John Herringer, associate director of standards interpretation for The Joint Commission. "That is an important factor. If it is a low-volume person, you will have a small amount of data. But you do need to be collecting it."

First, determine which practitioners have data and which don't, and then determine why data are missing for certain practitioners and how you can get them.

"If the correct data are available and they are not getting funneled to you, that is another issue," says Herringer. "I am a firm believer that organizations have a lot more data than ever gets to the medical staff."

Herringer recommends meeting with your information technology (IT) and billing departments to find out what data are currently being collected, what format they are collected in, how often they are aggregated, if they are being shared with the correct departments, and if not, what it would take to correct this. If data are being looked at but not often enough, or if the right people aren't looking at them, you'll need to redesign your process.

Basically, you need to figure out what is currently happening at your organization and then tweak your process, Herringer says. "If you don't have data for everybody, figure out how you can get it," he says. "It sounds daunting, but I think that people are further along than they think they are. You may not have a good handle on how much data are already being collected. Once you sit down and research this, then you can fill in the gaps."

Individual departments should identify what they think is useful data, since the signs of good care will be different for each area. For example, the department of internal medicine might decide to look at whether the dose of medication or liter flow for the oxygen can be reduced for congestive heart failure patients, which is more detailed information than simply determining that a patient had no infection after surgery and was discharged in five days.

After the medical staff approve whatever the department says is a comprehensive, appropriate set of data to collect, your organization would then go about analyzing the data as they become available, and taking any actions necessary.

"At this point we're not prescribing this to be done monthly or quarterly. But if it is done every 12 months, I would classify that as periodic and not ongoing," says Herringer.

But at the same time, small amounts of data could be meaningless. "You could have two problem cases, but if it's two out of 500 cases a year, it may not be any kind of a pattern or trend," says Herringer.

Each organization needs to decide how much data are looked at and how often, but data do need to be collected for everyone, Herringer says. He acknowledges that there are some practitioners who will be difficult to collect data for, such as psychiatrists, because they don't do a lot of procedures other than admissions for certain diagnostic labels. If the patient gets discharged, that is clearly a good outcome because then the patient didn't need to be institutionalized; otherwise, it is very hard to collect practice data for confidential sessions, notes Herringer.

"You are not sitting in the room making judgments as to whether he is using the correct clinical approach, and the documentation won't necessarily reflect why a certain approach or medication was used," he says. "So they are a hard group to get a handle on."

Since direct observation won't work for this group, other options are chart review, monitoring of diagnostic and treatment approaches, and medications that are being prescribed.

Another group that is difficult is physician's assistants and dependent advanced practice nurses, because their work is often coded under their supervising practitioners. "So they will have some data, but it won't necessarily be linked to them. If one physician's assistant is working for three or four physicians in a practice group, it could be hard to pull that out," says Herringer.

However, there are ways in which data could be pulled from an automated record since every employee would presumably have an access code. Herringer advises working with IT to create a report on the number of times the practitioner wrote a progress note, or ordered a diagnostic test, or identified the patient. If you don't have an automated record, you might need to go in manually and review the records to extract the data.

Another challenge when locating data to put into the performance assessment is the issue of "active" staff, says Swain. If physicians don't admit, which is popular with hospitalists taking a larger role in hospitals, it will be difficult to get some of the hospital-related information, she explains.

However, all the occurrence data, such as generic screens, incident reports, and complaints from staff and patients, need to be classified by provider and submitted to the medical staff office. Other information such as blood and drug use, appropriate screening for procedures, infection information, and core measures data by provider are rich in performance review material, adds Swain.

"The change will be to systematically record it in the medical staff office," she says.

Gather a planning team with IT staff, nurses, ancillary staff, and administrators, to ferret out all the data streams of information at your organization, recommends Swain. Since the medical staff office has been on the sidelines of much of the clinical activities, they do not have insight to all the opportunities for provider data, she says.

"Pharmacists know about who orders off formulary too frequently, and nurses know who never calls back or who saves the day when no one else will respond," says Swain. "Good and bad, positive and negative, are all important now."

National Patient Safety Goal information needs to be funneled into the mix, adds Swain. "Who is always having problems pausing prior to a procedure? Who seldom responds to a critical result?" she asks.

Incorporate data on patient safety measurements, such as do-not-use abbreviations, suggests Christina W. Giles, CPMSM, MS, president of Nashua, NH-based Medical Staff Solutions. "Note that a practitioner never uses the disapproved abbreviations, that there have been no problems with legibility of handwriting, and kudos letters received from patients and their families," she says.

Data may already be reported to entities such as The Joint Commission, the Centers for Medicare & Medicaid Services, or large insurers. "If these data are already being collected, then we should be documenting them for the privileges requested as well," Giles says.

Some institutions are developing the use of a process similar to the "360-degree" assessment used in human resources, with individuals who work with the particular practitioner asked about his or her communication skills, professionalism, medical knowledge, overall patient care, and use of evidence-based practices, says Giles.

The Joint Commission gives suggestions for methodologies to collect data to comply with standard 4.40, including direct observation, chart review, and interviews with other team members about their treatment approach.

"I think you can use the same approach for focused review," says Herringer. "If you are seeing infections related to certain surgeons, you could have another surgeon watch the technique and see if they can identify any breaks in infection control."

Have that individual do a chart review to see if the physician is doing the right cultures, ordering the right medications, noting signs and symptoms of infection, and possibly identify some areas requiring additional education or training, recommends Herringer.

If the medical staff decide to use proctoring as an evaluation technique, they must establish a policy and procedure that defines how the proctoring will take place, what information will be collected, the roles and responsibilities of the proctoring physician and of the proctored physician, and where the information will be sent for review, says Giles.

To collect and aggregate all the data is going to be difficult, and will require merging the various databases being used throughout the hospital so that this information aggregation is not done by hand, says Giles. Work with clinical practitioners to identify the correct measures, then determine the best way to portray the information, she advises.

"This will impact a lot of individuals who have been working hard to try and achieve this for many years," says Giles. "I see The Joint Commission's standards as providing the impetus to accomplishing this sooner rather than later."