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Meeting The Joint Commission Ongoing Physician Practice Evaluation Standards January 2009 Kenneth J. Abrams, MD, MBA Senior Vice President, Clinical Operations,

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Presentation on theme: "Meeting The Joint Commission Ongoing Physician Practice Evaluation Standards January 2009 Kenneth J. Abrams, MD, MBA Senior Vice President, Clinical Operations,"— Presentation transcript:

1 Meeting The Joint Commission Ongoing Physician Practice Evaluation Standards January 2009 Kenneth J. Abrams, MD, MBA Senior Vice President, Clinical Operations, Associate Chief Medical Officer, North Shore-Long Island Jewish Health System

2 1 Ongoing Professional Practice Evaluation (OPPE) The intent of the standard is that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis rather than at the two year reappointment process, to allow them to take steps to improve performance on a more timely basis. A clearly defined process would include but not be limited to: –who will be responsible for reviewing performance data MEC, Credentialing Committee, Department Chair, Department, etc. –how often the data will be reviewed 3, 6, 9 Month intervals. 12 Month intervals considered periodic not ongoing –the process to be implemented to use the data to make decision as to whether to continue, limit or revoke privileges. Who can make and approve an action –how data will be incorporated into the credentials files. The decision resulting from the review, whether it be to take an action or to continue the privilege would need to be documented along with the supporting data. - Adopted from The Joint Commission

3 2 Joint Commission Physician Credentialing Requirements The following information is suggested to be reviewed on a regular basis as part of ongoing practice evaluations of physician performance, in addition to the every 2 year credentialing cycle: –Review of operative & other clinical procedures performed and their outcomes –Adverse events / sentinel events –Pattern of blood and pharmaceutical usage –Requests for tests & procedures –Length of stay patterns –Morbidity and mortality data –Practitioners use of consultants –Other relevant criteria as determined by the medical staff Departments need to define the type of data to be monitored. Departments would know best which data would best reflect good and problem performance Suggestions for collection of data: periodic chart review direct observation monitoring of diagnostic and treatment techniques discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel. - Adopted from The Joint Commission

4 3 Typical Effort Improving Clinical Practice Patterns Data Collection Data Reporting Data Analysis Strategy Development & Deployment Leveraging automated data reduces manual chart review and allows increased time for analysis and problem solving – the key to improving care! Ideal Effort Premier Tools Are Designed to Shift the Data Collection Effort Curve

5 4 Results of the Evaluation The information resulting from the evaluation needs to be used to determine whether to continue, limit, or revoke any existing privilege(s) at the time the information is analyzed. Examples: –determining that the practitioner is performing well or within desired expectations and that no further action is warranted –determining that issues exist that require a focused evaluation –revoking the privilege because it is no longer required –suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it they must request a reactivation –determining that the zero performance should trigger a focused review (MS.4.30 EP 5) whenever the practitioner actually performs the privilege. –determining that the privilege should be continued because the organization's mission is to be able to provide the privilege to its patients - Adopted from The Joint Commission

6 5 Focused Professional Practice Evaluation An intense assessment of a practitioners credentials and current performance –New doctors applying for staff privileges –Practitioners requesting new or expanded privileges –Lack of documentation of competency –Triggered by a negative evaluation (criteria should be specified) –Practitioner lacks required case volume Proctoring – a form of Focused Professional Practice Evaluation –Evaluation of a practitioners performance by another peer Real time – direct observation Retrospective evaluation by same specialty internal or external review.

7 6 Engage Medical Staff with Severity-Adjusted Data Premier Clinical Advisor Clinical Performance Physician Performance Financial Performance Patient Safety Strategic Planning Regulatory Compliance

8 7 Physician Profiles Engage Your Medical Staff Key Applications: –Support physician re-credentialing process –Identify physician practice pattern variances –Identify cost reduction opportunities Value: –Improve compliance with JCAHO PI standards –Reduce staff time generating reports Physician Performance Physician Profile Report

9 8 Physician Profiles Engage Your Medical Staff Compare performance for: –Individual physicians –Physician groups Understand physician performance for: –Outcomes –Costs & ALOS –Resource Utilization Physician Performance 9/01/2005 through 10/30/2006 8/01/2006 through 10/30/2006

10 9 Drill to Physician Performance from any Report ALOS / Cost Analysis Report Physician Performance on outcome metrics using Report Builder Analyze Physician Performance on Clinical Outcomes & Efficiency Physician Performance

11 Physician Activity & Outcome Report State of the Art Performance Based Measurement

12 11 Pre Practitioner Measurement Process measures dominated Raw numbers were substitutes for performance Data was not risk adjusted Benchmarks were not utilized Peer performance was not a standard Limited focus on resource consumption No patient satisfaction data

13 12 Evolution in Measurement Multiple domains are necessary to evaluate complex performance Outcome trumps process Risk adjustment levels the playing field Excess resource consumption consistently associated with poor outcomes (Dartmouth) Patient comments on perception care offer valuable insight beyond statistical rankings Safety indicators offer insight into benchmarked rates of complications of care

14 Medical Record Data Source - Input Medical Record Content And Data Sources Medical Record Content And Data Sources ADT Patient ID Medical Record Admit Source Admit Type Admit Date Patient Type Patient Classification Discharge Status Patient Origin Patient Demographics Birth Date Age Race Gender Clinical DRG 3M APR-DRG PX (Primary & Secondary DX (Primary & Secondary) Days on MV Qty Ordered Service Date CPT4/HCPCS Financial Payor Secondary Payor Charges (Dept & Procedure) Costs ( Dept & Procedure) Fixed Cost/Px Variable Cost/Px Physician Specialty Attending Consulting Surgeon Outcomes ALOS Readmits Complications Mortality Outliers ORYX Indicators Birth Weight 13

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16 15 Report Includes: Activity of discharges and procedures (data risk adjusted / benchmarked) Length-of-Stay Readmission Mortality Complications Patient Safety Indicators Core Measures Denials Liability Claims Press Ganey

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23 Patient Satisfaction (Press Ganey) 22

24 Patient Satisfaction (Press Ganey) Contd 23

25 24 Limitations Administrative data Does not capture activities for: ED Radiology Anesthesiologist (except interventional) Currently, most non-procedural consultants are not mapped for activity Attribution in group practices not developed Low volume reports have limited value Cost data is based charges

26 25 Improvement Timetable October 2008 Begin data capture for Ambulatory Procedures January 2009 Start data capture for Consulting Activities September 2008 Begin mapping groups (Hospitalist, OB/Gyn, etc.) Winter 2009 Web access for individual MD reports

27 QualityAdvisor Practitioner Profiles Conceptual Design and Prototypes Richard Bankowitz, MD, MBA. Vice President, Medical Director, Premier Healthcare Informatics

28 27 QualityAdvisor Practitioner Profile Interactive online reporting Custom Comparison Groups All Provider type option to capture all patients, regardless of role Report Sections –Demographics –Outcomes (in aggregate and trended) Customize inclusions Mortality, Morbidity, Complications, LOS, Cost, Charges, Readmissions –Complications CareScience, AHRQ PSI, CMS HACs, Premier HACs –Customized Resource Use –Top Opportunities Mortality, LOS, HACs –Core Measure Compliance –Patient Flow Drilldown to Patient Level Data –Mortality, Complications, and Readmissions

29 28 Design Principles for Physician Reports It should be easy to see where there are problems (opportunities) – There should be a summary view and an opportunity view –Put all high level information in one place –Use green, yellow, red or other easy to interpret icons (consider printing) –Every metric needs some sort of target (expected value or other target) –The report must display variance from target and flag opportunities (red) Make the summary level clear and concise and put supporting information in drill down detail section – graphs etc. can go in detail Users should be able to select which metrics they will see in the top level summary display, and alter this by physician group (med vs surg) Users should have the ability to customize the peer comparison group Users should be able to see best practice performance Users should be able to choose which drill downs will display / print Users should see trended data over time Users should be able to drill to find special cause variation Data must be aggregated in meaningful, actionable clusters

30 29 Define the patient population and peer group. Describe population characteristics. Highlight priorities for action. Graphically display key metrics and comparisons. Mock-up

31 30 Understand utilization variation.

32 31 QualityAdvisor Premier Hospital Acquired Conditions There are a number of secondary diagnoses that, when they occur after admission, Premier considers morbid, and should both be tracked for incidence and for patient identification Examples include –Anaphylactic Shock –Fat Embolism – Adverse Drug Event – Other 99 codes Surgical Comps Urinary Comps Neurologic Comps – C. Diff Enteritis – Sepsis/Bacteremia – 2ndary Thrombocytopenia – Phlebitis/Thrombophlebitis – Hemorrhage – Cardiac Arrest – Etc.

33 32 System Level Reporting Capability Corporate System 3System 2 System 1 Hospital AHospital BHospital C MD II MD III Outcomes and resource utilization tied from patient level all the way to corporate Security access defined for each level Start at any level in the roll up Patient … … Region ARegion BRegion CRegion D MD I

34 33 Targeted Population Analysis Specific populations targeted for detailed analysis –Heart Failure –Acute Myocardial Infarction –Pneumonia –Stroke Layered Dashboard reporting for online interaction –Control Charts –Drilldown to physician & patient level data Integrated Evidenced-based data –Core Measures –Resource Utilization –Hip & Knee Surgery –Pregnancy –Cardiac Bypass Surgery –Spine Surgery

35 34 Top Performer Expected Mock-up

36 35 Readmission Reporting Risk-adjusted 30-day Readmission Report –Risk of being readmitted based off of initial diagnoses Readmission Diagnosis Summary Report –Actual readmission rates for specific diagnoses –Flexible readmission timeframes (eg, 7, 14, 30 days, or user defined) Drilldowns –Readmission Detail (all patients) –Readmission Individual Patient Detail (one patient, multiple admissions)

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