0. 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

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

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
Practitioner’s 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

3. Premier Tools Are Designed to Shift the Data Collection Effort Curve
Typical Effort
Ideal Effort
Improving Clinical Practice Patterns
Greatly alleviates the need to do chart-reviews by using readily available electronic data (UB92 patient-level) in conjunction with our data loading and validation tool.
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!

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

5. Focused Professional Practice Evaluation
An intense assessment of a practitioner’s 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 practitioner’s performance by another peer
Real time – direct observation
Retrospective evaluation by “same specialty” internal or external review.

6. Engage Medical Staff with Severity-Adjusted Data
Premier Clinical Advisor™
Strategic Planning
Patient Safety
Clinical Performance
Physician Performance
Now lets move into how Clinical Advisor can work with your organization around physician performance.
Regulatory Compliance
Financial Performance

7. Physician Profiles Engage Your Medical Staff
Performance
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
Clinical Advisor has a number of methods that allows for analysis on physician performance. This is the Physician Profile report is a great report with CA that provides a snapshot of a physician’s performance on clinical outcomes and cost, as compared to other physicians in the hospital and a peer group.
Many hospitals use these reports
-as part of the re-credentialing process
-compliance with JCAHO standards
They allow you to
-identify opportunities at the physician level in outcomes and cost
Physician Profile Report

8. Physician Profiles Engage Your Medical Staff
Performance
8/01/2006 through 10/30/2006
Compare performance for:
Individual physicians
Physician groups
Understand physician performance for:
Outcomes
Costs & ALOS
Resource Utilization
9/01/2005 through 10/30/2006
The Physician Profiles use severity-adjusted data, using the same 3M APR-DRG methodology we discussed earlier.
The Physician Profiles can be run for an individual physician or a group of physicians as an aggregate.
In the highlighted section of the Physician Profile report (section blown up) we can see how the report compares an individual physicians performance (red bar) on ALOS, Average Cost, and Mortality versus:
-the performance of the other physicians at their hospital in the same practice (dark blue bar)
-the performance of all other physicians at their hospital (white bar)
-the performance of all other physicians in the same specialty at hospitals in a defined peer group
-the performance of all other physicians at the hospitals in a defined peer group (purple bar)
The highlighted section of this report uses severity-adjusted index values to show how a physician is performing vs. other physicians.
-We can see that the physician’s (red bar) ALOS is 34% higher than what is expected for their patient population.
-We can see that the physician’s (red bar) Cost per Case is 96% higher than expected
-We can see that the physician’s (red bar) Mortality rate is 58% higher than expected, and the other physicians in the same specialty in the hospital have a 41% better than expected mortality rate.
This report takes into account all patients that the physician treated by physician role. For example, you can run this report for a physician, where the physician was the attending physician. The data/patients included in the report will be all patients in the timeframe the physician treated as the attending physician. The Physician Profile report can be run for multiple physician roles, which include:
-Attending Physician
-Admitting Physician
-Consulting Physician
-Procedure Physician
Presenter’s Note:
technical note: the severity-adjusted indexes are a measure of how a physician (or group of physicians) performs against how they are “expected” (expected values from the database) to perform. This comparison of actual vs. expected results in an index value, where:
-an index of 1.0 = performing as expected
-an index of 1.10 = performing 10% higher than expected
-an index of 0.90 – performing 10% better than expected)
Physician Profile Report

9. Drill to Physician Performance from any Report
Analyze Physician Performance on Clinical Outcomes & Efficiency
ALOS / Cost Analysis Report
The Physician Profile report is just one way to analyze physician performance within Clinical Advisor. Within other reports, you can drill down to the physician to better understand their performance.
The first report is an ALOS/Cost analysis report. Here we are looking at our Pneumonia population, and have drilled down to the attending physicians that treated these pneumonia patients, to better understand how the physicians perform on cost and los within this population.
The second report was built using Report Builder, Clinical Advisor’s ad hoc reporting tool. Report Builder allows you to analyze any set of data you choose.
Here our interest is looking at the outcomes and PSI event rates for physicians.
Physician Performance on outcome metrics using Report Builder

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

11. Pre 2008 - 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

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

13. Medical Record Data Source - Input
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
Not abstracted data. Pt level existing data. Calculated based on administrative data. 13

14. 14

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

16. 16

22. Patient Satisfaction (Press Ganey)22

23. Patient Satisfaction (Press Ganey) Cont’d23

24. Limitations Administrative data Does not capture activities for:
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

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

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

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
For the practitioner profile itself, the following features are included. Specifically, users will be able to create a custom comparison group at the facility level – allowing customers to create a group that best fits who is being measured, like a group of hospitalists or splitting out hip and knee orthopedic surgeons from spine surgeons. The report will be flexible so that you can design it to only include a subset, or batch, of reports. In addition, it will offer drilldown to patient level data for specific outcomes like mortality and hospital acquired conditions.

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

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

30. Understand utilization variation.

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.
In addition to the CMS Hospital Acquired Conditions, Premier has developed what we are calling “Premier Hospital Acquired Conditions”. These are conditions that we felt were morbid and should be tracked if they occur admission. We will be calculating them like the CMS HACs, where they will be defined using coded data (eg, will be one or more diag and/or procedure codes), looking for when specific diagnoses did NOT have a POA flag present, meaning they occurred after admission.
Premier has developed about 50 or so HACs that you will be able to track in QualityAdvisor, and you can see some of them, like the C. Diff enteritis, are under consideration by CMS. Therefore, you will be able to proactively track your performance on these measures well in advance of CMS deeming them non-reimbursable.

32. System Level Reporting Capability
Corporate
Region A
Region B
Region C
Region D …
System 1
System 2
System 3
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 …
QualityAdvisor, in conjunction with all Premier Products, is introducing new entity management to support system level reporting.
At first release, QualityAdvisor will Support Corporate, Hospital, Physician, and Patient-level reporting. The additional Regional & System levels will be introduced in subsequent releases following the initial release.
Our goal is to allow you to enter reporting at different levels, and control drilldown from that level. Security will be defined for each level.
Hospital A
Hospital B
Hospital C MD I MD II MD
III
Patient

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

34. Mock-up
Top Performer Expected

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)
Here is an example of the Risk-adjusted 30 day readmission report. This was designed with customer feedback as well as input from Premier Research Services and Richard Bankowitz, MD – VP and Medical Director. You’ll see that we not only show the risk for 30-day readmissions, but also information on length of stay for the readmission and the initial admission.
The user is able to drilldown from this report to identify exactly which patients were readmitted, and then from the patient list, and drilldown to a single patient view of a side-by-side comparison of that patients multiple admissions.