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Storing quality data across departments

Credentialing Resource Center Connection, January 22, 2009

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

Spurred by the introduction of ongoing professional practice evaluations (OPPE), focused professional practice evaluations (FPPE), and a focus on the privileges-competency link, the medical staff services department (MSSD) and quality departments find themselves working together more than before. Together, they are working to develop, collect, monitor, and report performance data. Typically the summarized data resides in the MSSD where it is analyzed on an ongoing basis to determine if a practitioner’s privileges should be continued, limited or revoked.

In recent weeks, I have worked with three different academic medical centers. At each facility I found that performance data for individual practitioners resided in the individual departments rather than the MSSD. Additionally, the involvement of the MSSD and the quality departments in establishing, collecting, and reporting competency data at these facilities varied. As is the culture in academic settings, the individual departments at each of the facilities knew exactly the kind of care being provided and had established quality indicators used to collect and monitor performance data for individual practitioners. However, the data was not readily available in a meaningful reporting format and neither the MSSD nor the quality department was aware of the scope of the performance monitoring on individual practitioner that resulted in the data.

Individual practitioner data should reside where it is readily available for use in evaluating competency. Departments, particularly in the academic environment, may insist that they be the keeper of individual practitioner’s performance data. However, the organization will need to determine the best approach for maintaining and reporting this information. The rationale for the information to reside in both the MSSD and the individual department so the MSSD knows and can substantiate through documentation that ongoing assessment of the practitioner’s proficiency linked to privileges is occurring.  Otherwise, you may find that come survey time you are being asked, “Where’s the beef?”

Remember, credentialing has no other master than the patient.

That’s all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS
http://www.greeley.com/consulting.cfm

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