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Tip of the week: Be smart about collecting data to use in your physician competency reports

Medical Staff Leader Connection, January 30, 2008

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Last week, we discussed selecting the right indicators for your physician competency report. Once you have selected the appropriate indicators for each of the six core competencies, it is time to start collecting data, but this can be a challenge for many hospitals with limited data collection resources. The following four steps will help your hospital collect data efficiently:

1. Form a task force. A medical staff task force comprised of a handful of physicians and representatives from administrative departments can help determine which competency measures should be included in the initial feedback report and how to gather those data. Once such decisions are made, the responsibilities for producing the physician competency report can be turned over to a specific department (i.e., the quality department or the MSO).
2. Perform a data systems inventory. Take an inventory of potential sources for physician performance data. Most hospitals rely on the centralized computerized billing system, which contains patient care data from medical records that is coded according to standardized criteria. But keep in mind that data can be scattered throughout the hospital's individual departments, and is not always in electronic format.
3. Catalog all competency measures. Once you have identified all of your data sources and systems, make a list of all potential indicators, including current medical staff indicators, hospital performance measures that may be relevant to physicians, and potential measures that your data systems can produce but have not been requested in the past. Review this list to determine which indicators are relevant to physicians, which would be most efficient and fair, and whether the data can be reasonably attributed to a specific physician. Determine which competencies the remaining indicators address. This will give you a starter list of potential indicators for your initial competency feedback report and highlight where you have gaps in all six general competencies. 
4. Create an indicator implementation plan. In making a realistic assessment of your data collection capabilities, you will probably find that some of these measures cannot be collected immediately. But just because you can't have that information today does not mean you should drop measures from your list. Assign each indicator to a development phase:
1. Already being measured
2. Minimal effort needed to implement
3. More effort needed but within current organizational capabilities
4. More staff or electronic resources needed

For more information on collecting physician competency data, please see Measuring Physician Competency: How to Collect, Assess, and Provide Performance Data by Robert Marder, MD; Mark Smith, MD; Marla Smith, MHSA; and Vicky Searcy, CPMSM.

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