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Medical Staff Standards For A Clinical Leader Part 2 V2
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Medical Staff Standards For A Clinical Leader Part 2 V2

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Outline of application of the Joint Commission Medical Staff Standards for a academic division of employed physicians

Outline of application of the Joint Commission Medical Staff Standards for a academic division of employed physicians


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  • 1. 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
  • 2. Introduction
    The following contains details on the application of the medical staff standards in an academic division of internal medicine. Contents include:
    Framework for Quality
    Organizational hierarchy and assumptions
    Clinical data reporting hierarchy
    Clinical services under Internal Medicine and Adult Primary Care
    Employment models and staff categories
    Sources of data for practitioner evaluation
    Methods of practitioner reporting
    Professional Practitioner Evaluation
    Framework – Cycle of evaluations
    Focused Professional Practitioner Evaluation (FPPE)
    Ongoing Professional Practitioner Evaluation (OPPE)
    Continuous Professional Practitioner Evaluation (CPPE)
    Example of proposed OPPE for Internal Medicine and Adult Primary Care
  • 3. 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)
  • 4. Medical Staff Standards – Internal Medicine
    Internal Medicine within the Medical Center Hierarchy
    Hospital
    Medical Staff
    Administrative activities of the Division
    Chief, Division of Internal
    Medicine – accountable individual
    Organizational assumptions
    Transparency
    Practitioner clinical autonomy
    Alignment of strategy, tactics and operations
    Balanced compensation program
    Appropriate staffing model and support
    Information technology infrastructure
    Internal Medicine
    and Adult Primary Care
    Clinical activities of the Division
    Residents
    Medical Students
    Nurse
    practitioners
    MD/DO
    Division of Internal Medicine and Adult Primary Care
  • 5. Hierarchy for clinical reporting
    Medical Staff
    PCA Committee
    PPE
    Case reports
  • 6. Medical Staff Standards – Internal Medicine
    Clinical services in Internal Medicine and Adult Primary Care
    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
  • 7. Medical Staff Standards – Internal Medicine
    Employment arrangements and clinical status
    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
  • 8. 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 Medicine
    Sources of individual practitioner clinical and administrative data
  • 9. 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 Medicine
    Methods of practitioner reporting
  • 10. The Professional Practitioner Review Process
  • 11. Cycle of practitioner evaluations
    Continuous
    Professional Practitioner
    Evaluation
    (CPPE)
    monthly
    Continuous Professional Practitioner Evaluation is not described in the Joint Commission standard
    Ongoing Professional Practitioner Evaluation (OPPE) – every 2 years
  • 12. 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 Medicine
    Focus Professional Practitioner Review (FPPE) – new faculty (full or part time)
  • 13. 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 Medicine
    Focus Professional Practitioner Review (FPPE) – chief medical residents
  • 14. 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 Medicine
    Ongoing Professional Practitioner Review (OPPE)
    * - metrics revised annually based on clinical and business requirements of the practice
  • 15. 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 Medicine
    Continuous Professional Practitioner Review (CPPE)
    * - metrics revised annually based on clinical and business requirements of the practice
  • 16. 2010 Metrics
    Internal Medicine and Adult Primary Care
  • 17. 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
    wRVUsper 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*
    Medical Staff Standards – Internal Medicine
    2010 metrics
    * - denote measure used in annual incentive compensation calculation
  • 18. Practical approach to completing a professional practitioner review
    Process review and examples of reports and paperwork
  • 19. Outline/list clinical work clinician provides
    Clinical areas
    % effort
    Quantitative report results
    Practice demographics
    Quality
    Diabetes
    Narcotic consistency in prescribing
    Engagement
    Clinical teaching activities
    Practice measures
    Incomplete medical records
    Problem list completion
    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
    Medical Staff Standards – Internal Medicine
    Process – Professional Practice Evaluation
    * - denote measure used in annual incentive compensation calculation
  • 20. 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.