This document discusses the application of medical staff standards in an academic division of internal medicine. It outlines the organizational hierarchy, sources of data for practitioner evaluation, and methods of practitioner reporting. It describes the framework for quality and different cycles of practitioner evaluation, including continuous, ongoing, and focused reviews. An example is provided of proposed metrics for ongoing practitioner reviews in internal medicine and adult primary care.

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.