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Tip of the week: Select appropriate indicators for your physician competency report

Medical Staff Leader Connection, January 23, 2008

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In the past, hospitals created their own indicators for evaluating physician performance, but today, they can pick and choose from a plethora of national standards, including those from The Joint Commission (formerly JCAHO) and the Centers for Medicare and Medicaid Services. However, not all national standards are appropriate for evaluating physician competency. In addition, they do not currently cover all of the six core competencies. This means that medical staffs still need to go through the process of selecting physician performance measures, using national standards as a guideline.

When selecting performance indicators, keep the following criteria in mind:

• Relevancy: Is it relevant to physician performance?
• Competency: Does it relate to an important expectation?
• Type: What type of indicator (i.e. review, rule, or rate) would be most appropriate?
• Data source: Should the data come from clinical documentation, incident reports. or perception surveys?
• Attribution: Can it measure individual physician performance with reasonable reliability and accuracy, or is it effective only when measuring the performance of the medical staff or specialty as a group?
• Availability: How readily can the data be accessed?
• Benefit: Is the cost of the measure worth the improvement benefit?

To learn more about selecting performance indicators, please see Measuring Physician Competency: How to Collect, Assess, and Provide Performance Data, Second Edition, by Robert Marder, MD; Mark Smith, MD; Marla Smith, MHSA; and Vicky Searcy, CPMSM.

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