You'll need performance data for all practitioners

Collecting data for complex practitioner groups

The Joint Commission's new 2007 medical staff standards require you to collect performance data for all practitioners. For most practitioners, this will be a simple and straightforward matter, but for others, it could prove to be a daunting challenge. Here are several examples:

Low-volume practitioners

"Obviously, you will have a limited set of data for low-volume people," says John Herringer, The Joint Commission's associate director of standards interpretation and lead interpreter of medical staff standards.

Depending on what the data show, they may or may not be useful, adds Herringer. "Just because somebody did two procedures and both patients died, doesn't mean there is a problem. They could have had multiple comorbidities and the physician was managing the case as best he or she could," he says.

Conversely, if the two procedures go well, it doesn't mean he's got a good track record either — the data could be meaningless because there was an insignificant number, says Herringer.

At Swedish Medical Center in Seattle, the solution for low-volume practitioners has been to separate membership from privileges, says Nancy J. Auer, MD, FACEP, chief medical officer. "We are in the process of changing our bylaws, so that low-volume providers who want to be active can achieve that status by active service on committees, attending Swedish-sponsored CME, being in a group that has a certified quality improvement program recognized by Swedish, or maintaining a certain number of patient contacts," she says.

Privileges will be based on education and experience for initial appointment, and maintaining activities to retain privileges, says Auer.


These physicians don't do a lot of procedures, and a lot of their work is confidential. "You won't be sitting in the room making a value judgment about how well he is interacting with the patient," says Herringer. In addition, the detail of the documentation in the charts could be limited or protected under state confidentiality laws.

If the patient is discharged, that indicates his or her condition improved from admission so that is a good outcome, notes Herringer. "Obviously if they do electroconvulsive therapy, then you will have procedures and outcomes data," he says. "You can also monitor their prescribing patterns. But in terms of interpersonal skills, it's a hard thing to do because you can't see it."

Physician's assistants and advanced practice registered nurses who are dependent practitioners

This is another problematic group, since much of their activity is coded under their supervising physician. "If they are independent and can bill under their name, you can code under their name. Otherwise, this group is going to be difficult," says Herringer.

If you have an automated medical record and the practitioner uses a password or computer sequence of keys to authenticate their signature, it might be possible for you to work with your information technology (IT) department and run a report of every patient record in which they documented something. "It would be labor intensive to do a chart audit, but at least you could find out the 50 patients they were involved with, and that would be a starting point," he suggests. "When every single thing on a hard copy record or that is automated is coded under their supervisor, it is very hard to figure out which cases they were involved with.

"I am a very firm believer that there is much more data being collected in an organization than is ever funneled back to the medical staff," says Herringer. He recommends sitting down with the medical staff, your IT department, performance improvement, infection control, and your billing department to identify all the data that are currently being collected.

Then the next questions to answer are: Are the data being funneled to the medical staff? If they aren't, can they be? How long will it take for this to happen?

"Don't try to reinvent the wheel, because there is probably a lot more being collected than the medical staff ever see," says Herringer. For instance, every time a Medicare patient is seen, a DRG bill has to go out with a primary diagnosis and additional codes for comorbidities.

"If somebody develops an infection and they have to stay, it will at least give you information on the volume of the procedures, the activities, the admissions, and the volume of the comorbidities that you are coding," says Herringer. You can start to identify a large amount of data from all of the billing codes and analyze them.

"If you see one practitioner has a tremendous amount of infection or large numbers of returns to the OR, you might want to look at him to see if there were problems with the initial surgery or problems that weren't anticipated," he adds.

The next question to answer is: Who is currently looking at the data and how often, and do you need to change that? A department might look at data every month, but they need to have data for everybody, stresses Herringer. "You can't just keep meeting every month and then two years later say, 'Hey, we have no data for this guy,'" he says. "It may be that you have no data because he hasn't been there, but it also may be that you are not capturing it in the correct manner. You need to keep some sort of file that identifies who you do and don't have data for."

At this point, The Joint Commission is not requiring specific time frames for looking at data, but if you are only looking at them every 12 months, that would be considered periodic and not ongoing, says Herringer.

"The idea is to look at data as they become available so you can take action earlier," he says.

However, frequency is not the only thing to consider — data must also be useful and valid. For example, even if you look at monthly data for low-volume or sporadic practitioners, it might be meaningless data.

"You can look at them every month, but you might have to aggregate three months to get any significant number to look at, or re-look at them when you get at least 10 or 20 procedures, because it doesn't mean anything to look at one or two," says Herringer.

For some specialized procedures that might only be done two or three times a year, you might not look at them very often, since you really need to look at more than one at a time.

How to collect data

As for how to collect data, Herringer advises using the four methodologies listed at MS 4.40, which include chart review, direct observation, monitor diagnosis and treatment techniques, and discussions with other individuals involved in the care of the patient.

"So you can use any of those approaches," says Herringer. "The interviews are going to give you information about their interpersonal and communication skills. Systems-based practice in very simplistic terms is: Are they are a good team player?"

The practitioner needs to understand that health care is delivered through a variety of systems, including information management, scheduling, medication management, and diagnostic testing. They must be cognizant of how they relate to all of these other systems.

"Are they completing their H&Ps in a timely manner? Is the update on the chart when you have the patient in the OR, or are you trying to track them down saying, 'Wait a minute, we don't have your H&P, where is it?'" asks Herringer. "Is an order for a [CT] scan going down to X-ray with no indication of what you are supposed to look for?"

The idea of the physician as running the health care team is outdated — the physician is a member of the team and needs to provide information in a timely manner so that other people can do their jobs, says Herringer.

Discussions with team members can give you important information about how well the physician is practicing within all of the other systems. "It's a very hard thing to proactively go out there and look for. You tend to end up back-dooring it by looking at complaints, or problems with charting," says Herringer. "Discussions with other team members will give you that information."

Ask team members: Are orders complete? Are updates done? Does the physician give you the indication for a diagnostic procedure? "You can get a lot of information by asking people," says Herringer. "You don't have to wait for the problem to arise."

[For more information, contact:

Nancy J. Auer, MD, FACEP, Chief Medical Officer, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Phone: (206) 386-6071. E-mail:]