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Using the JCAHO's six competencies to evaluate MD performance

Hospitalist Management Advisor, October 1, 2006

Expectations that hospitals will use standardized indicators to measure practitioners’ competency and performance have increased as payers move toward pay for performance and consumers demand higher-quality care. Experts now anticipate that those expectations of data-driven measurement will eventually become requirements from the hospital industry’s leading accrediting agency, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

The JCAHO’s 2007 Medical Staff Standards emphasize ongoing measurement of practitioner competency in six general categories:

1. Patient care

2. Medical/clinical knowledge

3. Practice-based learning and improvement

4. Interpersonal and communication skills

5. Professionalism

6. Systems-based practice

The six general competencies, which were originally developed by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties for measuring resident competency, provide a new framework for hospitals to evaluate practicing physicians, says Robert Marder, MD, vice president of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. HCPro is the publisher of this newsletter.

“The question is, how well does this framework translate to practicing physicians? It’s one thing to say, ‘This is what you need to become a physician, or certified as a physician,’ ” Marder says. “How well does it relate to current competency? I think it’s an interesting question.”

Despite the drawbacks associated with data collection that many hospitals currently face (e.g., difficulty attributing outcomes to the proper physician), hospitals should consider the following options for measuring physician competency in the six categories:

1. Patient care. The introduction to the credentialing and privileging section of the JCAHO’s 2007 Medical Staff Standards states that physicians are expected to provide compassionate, appropriate, and effective patient care for the promotion of health, prevention of illness, and treatment of disease, as well as at the end of life.

The expectation to measure both compassionate care and appropriate and effective care in each of the areas described above is problematic because it combines technical performance with the “soft” quality of compassion, Marder says.

“From a [human resources] standpoint, you would never lump together your interpersonal skills with your technical knowledge,” he says. “Part of the issue here is, when you try to measure these categories, some of them [require the measurement of] multiple things. That’s going to be a challenge for hospitals.”

Marder suggests breaking the three qualities (i.e., compassionate, appropriate, and effective) and the areas of care (i.e., promotion of health, prevention of illness, treatment of disease, and care at the end of life) into a three-by-four matrix to determine how to measure each element. For the qualities of care, Marder says the following types of measures can be used:

  • Effective = outcomes (e.g., mortality rates)
  • Appropriate = processes (i.e., core measures, such as angiotensin converting enzyme inhibitors on discharge for heart failure)
  • Compassionate = communication with patients and families (e.g., informed consent)

    Marla Smith, MHSA, a consultant for The Greeley Company, says facilities can use checklists of physician behaviors to measure compassionate care, such as whether the physician shakes the patient’s hand and explains the patient’s diagnosis or treatment options in a clear and understandable manner.

    2. Medical/clinical knowledge. The JCAHO states that practitioners must “demonstrate knowledge of established and evolving biomedical, clinical, and social sciences, and apply that knowledge to patient care and educating others.”

    “It’s fine in training to measure medical knowledge because you have a test,” Marder says. “Is the measure of medical knowledge that [a physician has] maintained board certification? That may be all you need.” Marder suggests that documentation of continuing medical education may also serve to measure competency in this category.

    3. Practice-based learning and improvement. The JCAHO seeks proof that practitioners are able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

    “This is going to be tough to measure,” Marder says, unless hospitals define practice-based learning as the implementation of core measures (e.g., participation in preprocedure timeouts). However, hospitals should only use core measures that are physician-relevant.

    4. Interpersonal and communication skills. The JCAHO expects practitioners to demonstrate skills that enable them to establish and maintain professional relationships with patients, families, and other members of healthcare teams.

    Marder suggests that incident reports of staff or patient complaints regarding physician interpersonal and communication skills could be used to document noncompliance. Another way to measure these skills involves surveys of staff and patients.

    5. Professionalism. Practitioners are expected to demonstrate behaviors that reflect commitment to continuous professional development, ethics, and sensitivity to diversity, as well as responsible attitudes toward patients, the medical profession, and society.

    One way to measure competency in this category could be to document incidents of disruptive behavior or other examples of noncompliance with professional or ethical codes, Marder says.

    6. Systems-based practice. The JCAHO seeks evidence that practitioners demonstrate an understanding of the contexts and systems in which healthcare is provided and are able to apply this knowledge to improving healthcare. Examples of systems-based practice include patient advocacy and coordination of care between levels of care and among teams.

    Marder says that competency could be measured based on utilization management data (e.g., correct use of resources such as blood transfusions, cooperation with patient safety practices, etc.).

    Other measurements could include compliance with the Situation-Background-Assessment-Recommendation technique for communication between members of the healthcare team about

  • a patient’s condition
  • preprocedure timeouts
  • order read-back requirements

    This expectation requires physicians to understand that they operate in a system with certain rules that take into account care beyond the physician-patient relationship.

    “Sometimes, the system has to override how you would like to operate,” Marder says.

    Using surveys to collect data

    For the measurement of competency in “soft” (i.e., nontechnical) categories such as compassion, professionalism, and interpersonal and communication skills, hospitals may need to rely on patient or staff surveys for data.

    “What you’re talking about is people’s perception, not hard data,” says Robert Marder, MD, vice president of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Hospitals should use perception data to measure soft categories. Marder says nurses and other staff are ideal for gauging physicians’ professionalism, communication, and other soft skills, although they should not be asked to rate physicians for clinical/technical quality, which can be assessed by more objective data.

    A survey might ask patients, allied health professionals, residents, or other physicians to rank a physician’s professionalism, communication, or compassion on a five-point scale (e.g., very good, good, average, poor, or very poor). Surveys can also ask patients to agree or disagree with statements about a physician’s care (e.g., “The doctor kept me waiting,” or “The doctor expressed interest and empathy.”)

    Data should be collected from a sample that is large enough to exclude any individual biases—although unbiased data can be difficult to obtain from patient satisfaction surveys.

    Patient satisfaction surveys are nonetheless valuable, Marder explains. “Is it appropriate to get perception data to fill in the gaps? The answer is, ‘Absolutely.’ ”

    Recruiting tip of the month: Fostering leadership potential

    Leadership development for a physician requires a comprehensive approach and lasts throughout his or her entire career.

    Hospitalist leaders can foster leadership in their organizations by proactively recruiting physicians with leadership potential.

    To do this, first determine whether a candidate’s skills and knowledge meet your organization’s needs.

    A well-constructed interview enables you to evaluate attitude, self-image, and social skills.

    The interview process should look below the surface to assess the candidate’s motives, values, and key personality traits.

    Traits to look for in physician leaders include

  • organizational agility
  • integrity and values
  • history of achievement
  • motivation
  • professional and personal goals
  • interpersonal and communication skills
  • ability to accept feedback and respond to coaching
  • leadership experience and potential

    Developing physician leaders

    To target and develop leadership potential in a physician, the key is to start early. Immediately introduce physicians to the organization’s goals, mission, vision, and core values, and discuss how these align with those of the physician.

    By clarifying expectations, the developing physician leader will better understand how his or her skills will help to lead the organization in multiple ways: clinically, as a business enterprise, and among peers and staff.

    Ensure that up-and-coming hospitalist leaders understand the expectations and specific responsibilities related to their job description. Communication and ongoing feedback and support are essential and send the message that you want to nurture the careers of physician leaders. This helps to increase job satisfaction and retention.

    Editor’s note: This tip was submitted by Paul Smallwood, vice president of physician search with St. Louis–based Cejka Search, a nationwide firm specializing in physician and healthcare executive recruitment. For more information on recruiting and retaining hospitalists, go to www.cejkasearch.com or call 800-678-7858.